The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function?
a. Continue to monitor the urine output.
b. Monitor for increased white blood cells (WBCs).
c. Assess that blisters and edema have subsided.
d. Prepare the patient for discharge from the burn unit.
ANS: A
The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury.
You might also like to view...
In a nursing unit, the RN delegates nursing tasks to the LPN. Keeping in mind the delegation guidelines, which statement denotes the right task for the LPN?
A) Make beds with the help of unlicensed assistive personnel. B) Assist clients with nasogastric tube feeds. C) Take orders from an in-house physician. D) Assess the client's needs and start an intravenous line.
The nurse is teaching a nutrition class for nursing students. The topic for today is nutrition therapy for diabetic older adults. What is the most important factor impacting glycemic control in adults?
A) People naturally lose weight as they age. B) Older adults eat less sugar than younger adults. C) Older adults metabolize carbohydrates differently than younger adults. D) Serum blood sugar levels rise with age.
A nurse has completed an in-depth community assessment on a local town to address rising levels of obesity and hypertension. What is the best next step?
A. Meet with local community members to establish realistic, culturally appropriate goals for the community. B. Hold a town hall meeting for everyone in the community to discuss the findings. C. Start planning a community fair so residents can start to get more information about healthy eating and exercise habits. D. Host a focus group to clarify information learned during the assessment.
A patient calls the clinic in a panic because she discovers she is pregnant after having unprotected sex
Shortly thereafter the patient ingested alcohol and acetaminophen. She is concerned about causing damage to the fetus. What should the nurse respond to the patient? A) "Why did you have unprotected sex if you had been drinking?" B) "You didn't know you were pregnant, so you haven't done anything wrong. The fetus isn't exposed to the mother's blood until after it implants, so the wedding's not an issue. But, don't have any more alcohol while you're pregnant." C) "Exposure to alcohol can cause facial deformities, low birth weights, and underdeveloped brains." D) "You didn't know you were pregnant, so you haven't done anything intentionally wrong. But alcohol is very damaging to the growing fetus, so you'd better be sure to stop drinking. Do you need any support for that?"