Nokea
Which one of the following is considered a reliable indicator for assessing the adequacy of fluid resuscitation in a 3-year-old child who suffered partial- and full-thickness burns to 25% of her body?
- A. Urine output
- B. Edema
- C. Hypertension
- D. Bulging fontanelle
Correct Answer: A
Rationale: Urinary output is a reliable indicator of renal perfusion, which in turn indicates that fluid resuscitation is adequate. IV fluids are adjusted based on the urinary output of the child during fluid resuscitation. Edema is an indication of increased capillary permeability following a burn injury. Hypertension is an indicator of fluid volume excess. Fontanelles close by 18 months of age.
You may also like to solve these questions
A male client is started on IV anticoagulant therapy with heparin. Which of the following laboratory studies will be ordered to monitor the therapeutic effects of heparin?
- A. Partial thromboplastin time
- B. Hemoglobin
- C. Red blood cell (RBC) count
- D. Prothrombin time
Correct Answer: A
Rationale: Partial thromboplastin time is used to monitor the effects of heparin, and dosage is adjusted depending on test results. It is a screening test used to detect deficiencies in all plasma clotting factors except factors VII and XIII and platelets. Hemoglobin is the main component of RBCs. Its main function is to carry O2 from the lungs to the body tissues and to transport CO2 back to the lungs. RBC count is the determination of the number of RBCs found in each cubic millimeter of whole blood. PT is used to monitor the effects of oral anticoagulants, e.g., coumarin-type anticoagulants.
The nurse is caring for a client with a history of peptic ulcer disease. Which medication should the nurse anticipate being prescribed?
- A. Omeprazole (Prilosec)
- B. Ibuprofen (Motrin)
- C. Cimetidine (Tagamet)
- D. Both A and C
Correct Answer: D
Rationale: Peptic ulcer disease is treated with proton pump inhibitors like omeprazole and H2 blockers like cimetidine to reduce acid production and promote healing. Ibuprofen, an NSAID, can worsen ulcers and is avoided.
The nurse is admitting a client with a suspected duodenal ulcer. The client will most likely report that his abdominal discomfort decreases when he:
- A. Avoids eating
- B. Rests in a recumbent position
- C. Eats a meal or snack
- D. Sits upright after eating
Correct Answer: C
Rationale: Duodenal ulcers cause pain relieved by eating due to buffering of gastric acid. Pain worsens when the stomach is empty. Resting or sitting upright does not directly relieve symptoms.
A client is admitted to the labor and delivery unit in active labor. The physician performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
- A. Fetal heart tones 160 bpm
- B. Moderate uterine contractions
- C. A large amount of straw-colored fluid
- D. Thick green amniotic fluid
Correct Answer: C
Rationale: After an amniotomy the nurse expects to observe a large amount of clear or straw-colored amniotic fluid indicating normal amniotic fluid. Fetal heart tones of 160 bpm are normal but not specific to amniotomy contractions are unrelated and green fluid suggests meconium which is abnormal.
Often children are monitored with pulse oximeter. The pulse oximeter measures the:
- A. O2 content of the blood
- B. Oxygen saturation of arterial blood
- C. PO2
- D. Affinity of hemoglobin for O2
Correct Answer: B
Rationale: The O2 content of whole blood is determined by the partial pressure of oxygen (PO2) and the oxygen saturation. The pulse oximeter does not measure the PO2. The pulse oximeter is a noninvasive method of measuring the arterial oxygen saturation. The PO2 is the amount of O2 dissolved in plasma, which the pulse oximeter does not measure. The affinity of hemoglobin for O2 is the relationship between oxygen saturation and PO2 and is not measured by the pulse oximeter.