To assess the child with severe burns for adequate perfusion, the nurse monitors
a. Distal pulses
b. Skin turgor
c. Urine output
d. Mucous membranes
C
Feedback
A Distal pulses may be affected by many variables. Urine output is the most
reliable indicator of end-organ perfusion.
B Skin turgor is often difficult to assess on burn patients because the skin is not
intact.
C Urine output reflects the adequacy of end-organ perfusion.
D Mucous membranes do not reflect end-organ perfusion.
You might also like to view...
The nurse admits an adult client to the Emergency Department who is unconscious and suspected of attempting suicide by overdosing. The client is accompanied by his roommate. The priority data for the nurse to gather from the roommate is:
1. Recent mental status. 2. Medications or empty bottles found in the home. 3. Relative to notify in case of emergency. 4. Past medical history.
Supplements of which of the following have been recommended as measures to prevent hip fractures in individuals older than 80?
1. Calcium and vitamin D 2. Phosphorus and selenium 3. Iron and Vitamin K 4. Vitamin B12 and potassium
The nurse is caring for a patient who has been on total parenteral nutrition (TPN) for 48 hours. Which action demonstrates effective nursing care?
a. Checking the patient's blood glucose level according to facility protocol. b. Increasing the infusion rate if the pre-scribed intake falls behind. c. Informing the patient that TPN can only be administered via a central line for 1 week. d. Monitoring the peripheral IV site of TPN infusion for signs of infiltration at least every 8 hours.
The nurse recognizes that the patient is at increased risk of infection due to the inability to replace which of these types of immunoglobulins?
a. IgM b. IgE c. IgA d. IgG