Nokea
A client is receiving fluid replacement with Lactated Ringer's after 40% of his body was burned 10 voluto hours ago. The assessment reveals: temperature 36.2°C; heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 mL for the last 2 hours. The I.V. rate is currently at 375 mL/hour. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for:
- A. Furosemide (Lasix).
- B. Fresh frozen plasma.
- C. I.V. rate increase.
- D. Dextrose 5%.
Correct Answer: C
Rationale: Low blood pressure, high heart rate, low CVP, and inadequate urine output indicate hypovolemia. Increasing the I.V. rate is appropriate to improve fluid resuscitation, as per burn fluid management protocols.
You may also like to solve these questions
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
- A. Notify the attending physician and blood bank.
- B. Complete the appropriate Transfusion Reaction Form(s).
- C. Stop the transfusion.
- D. Keep the I.V. open with normal saline infusion.
Correct Answer: C,D,A,B
Rationale: In a transfusion reaction, the nurse must first stop the transfusion to prevent further infusion of the offending blood. Next, keep the IV line open with normal saline to maintain access and support circulation. Then, notify the physician and blood bank for further evaluation and management. Finally, complete the transfusion reaction forms to document the incident.
The nurse receives the following critical laboratory results for a client with end-stage renal disease. The nurse anticipates the physician to prescribe which blood product? See the image below.
- A. Packed Red Blood Cells (PRBCs)
- B. Fresh Frozen Plasma (FFP)
- C. Albumin
- D. Platelets
Correct Answer: A
Rationale: End-stage renal disease often leads to anemia due to decreased erythropoietin production, making PRBCs the likely prescribed blood product to correct severe anemia. FFP, albumin, and platelets address other issues not typically primary in this context.
Which of the following hospitalized clients is at risk to develop parotitis?
- A. A 50-year-old client with nausea and vomiting who is on nothing-by-mouth status.
- B. A 75-year-old client with diabetes who has ill-fitting dentures.
- C. An 80-year-old client who has poor oral hygiene and is dehydrated.
- D. A 65-year-old client with lung cancer who has a feeding tube in place.
Correct Answer: C
Rationale: Dehydration and poor oral hygiene in the 80-year-old client increase the risk of parotitis due to reduced saliva production and bacterial overgrowth.
Which of the following discharge instructions would be appropriate for a client who has had a laparoscopic cholecystectomy?
- A. Avoid showering for 48 hours after surgery.
- B. Return to work within 1 week.
- C. Leave dressings in place until you see the surgeon at the postoperative visit.
- D. Use acetaminophen (Tylenol) to control any fever.
Correct Answer: B
Rationale: Returning to work within 1 week (B) is reasonable for laparoscopic cholecystectomy, depending on recovery. Showering is typically allowed after 24-48 hours (A is incorrect). Dressings can often be removed sooner (C), and acetaminophen is for pain, not fever control (D).
A client post-amputation is experiencing depression. Which nursing action is most appropriate?
- A. Administer an antidepressant immediately.
- B. Encourage participation in a support group.
- C. Limit discussions about the amputation.
- D. Schedule a physical therapy session.
Correct Answer: B
Rationale: Encouraging participation in a support group fosters emotional coping and peer support.