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NurseDive Free Nursing Practice Question
The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
A. Monitor for signs of seizure activity.
Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock.
Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets.
Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload.
Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.
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Full Explanation
A. Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.
Similar Questions
What age of onset of alcohol consumption is most predictive of alcohol addiction?
A. 12 or younger
12 or younger: While early onset is a risk factor, it is not as predictive as ages slightly older, where patterns of behaviour are more established.
B. 10 or younger
10 or younger: Very early onset is a risk factor but is less common and less studied.
C. 14 or younger
14 or younger: Research shows that starting alcohol consumption at 14 or younger significantly increases the risk of developing alcohol addiction.
D. 8 or younger
8 or younger: While extremely early onset is concerning, it is less predictive than slightly older ages due to the rarity and less data available.
Full Explanation
A. 12 or younger: While early onset is a risk factor, it is not as predictive as ages slightly older, where patterns of behaviour are more established.
B. 10 or younger: Very early onset is a risk factor but is less common and less studied.
C. 14 or younger: Research shows that starting alcohol consumption at 14 or younger significantly increases the risk of developing alcohol addiction.
D. 8 or younger: While extremely early onset is concerning, it is less predictive than slightly older ages due to the rarity and less data available.
A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for which most common cause of burn-related deaths?
A. shock.
Shock is a concern immediately after the burn injury due to fluid loss but is less likely after the initial 72 hours.
B. hemorrhage.
Hemorrhage is not a common cause of death following burns unless associated with a traumatic injury.
C. respiratory arrest.
Respiratory arrest: Respiratory complications are a concern, but infection remains the leading cause of death post-72 hours.
D. Infection.
Infection: After the first 72 hours, infection becomes the most common cause of burn-related deaths due to the compromised skin barrier and potential for sepsis.
Full Explanation
A. Shock is a concern immediately after the burn injury due to fluid loss but is less likely after the initial 72 hours.
B. Hemorrhage is not a common cause of death following burns unless associated with a traumatic injury.
C. Respiratory arrest: Respiratory complications are a concern, but infection remains the leading cause of death post-72 hours.
D. Infection: After the first 72 hours, infection becomes the most common cause of burn-related deaths due to the compromised skin barrier and potential for sepsis.
What is the best test to identify the risk of osteoporosis in postmenopausal women?
A. Skeletal x-ray
Skeletal x-ray: Skeletal x-rays can show bone loss but are not sensitive enough for early detection of osteoporosis.
B. Calcium blood level
Calcium blood level: Blood calcium levels do not directly indicate bone density.
C. Bone density scan
Bone density scan: Bone density scans (DEXA scans) are the gold standard for diagnosing osteoporosis and assessing fracture risk.
D. CAT scan
CAT scan: CAT scans are not typically used for assessing bone density.
Full Explanation
A. Skeletal x-ray: Skeletal x-rays can show bone loss but are not sensitive enough for early detection of osteoporosis.
B. Calcium blood level: Blood calcium levels do not directly indicate bone density.
C. Bone density scan: Bone density scans (DEXA scans) are the gold standard for diagnosing osteoporosis and assessing fracture risk.
D. CAT scan: CAT scans are not typically used for assessing bone density.