The nurse is caring for a patient 3 days following a split-thickness burn injury from a fire. Which of the following best indicates that nursing interventions to promote adequate cardiac output have been effective?
a. Urine output is 1,050 mL in 24 hours.
b. Radial pulses are thready at 112/min.
c. Blood pressure is 128/66 mmHg.
d. Patient weight is 4 pounds less than admission weight.
ANS: C
Patients with burn injury are at risk for fluid volume deficit and decreased cardiac output. The blood pressure reading is normal and indicates adequate cardiac output. The urinary output is low and indicates fluid deficit because urine output should be maintained at least 50 mL/hr (1,200 mL/24 hours). Thready peripheral pulses are indicative of low cardiac output. Weight loss could be indicative of fluid loss.
You might also like to view...
When a spinal cord injured patient is unable to tolerate food or fluids for a week or more, the nurse is concerned about which of the following metabolic alterations?
A) hypernatremia B) negative nitrogen balance C) hypothyroidism D) Cushing's syndrome
A patient tells the nurse she is going to try supplementing her selective serotonin reuptake inhibitor with St. John's wort. Which action should the nurse take first?
a. Assess the patient for depression and risk for suicide. b. Advise her of the danger of serotonin syndrome. c. Suggest that aromatherapy may produce even better results. d. Suggest she consider decreasing the dosage of her antidepressant.
The recommended weight gain during pregnancy for a woman who begins pregnancy at a normal weight is:
a. 10 to 15 lb. b. 15 to 20 lb. c. 20 to 25 lb. d. 25 to 35 lb.
Biobrane was applied to a patient's partial-thickness burn injury. Two weeks later, the nurse notices that the Biobrane is separating from the burn wound. The appropriate nursing intervention when this separation occurs is to:
A) Reinforce the Biobrane dressing with another piece of Biobrane B) Remove the Biobrane dressing and apply a new dressing C) Trim away the separated Biobrane D) Notify the physician for further emergency related orders