A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patient's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?
A) Obtain an order to reduce the rate of the patient's IV fluid infusion.
B) Report the patient's early signs of acute kidney injury (AKI).
C) Recognize that the patient is experiencing an expected onset of diuresis.
D) Administer sodium chloride as ordered to compensate for this fluid loss.
Ans: C
Feedback:
As capillaries regain integrity, 48 or more hours after the burn, fluid moves from the interstitial to the intravascular compartment and diuresis begins. This is an expected development and does not require a reduction in the IV infusion rate or the administration of NaCl. Diuresis is not suggestive of AKI.
You might also like to view...
Which belief best fosters provision of culturally competent nursing care? (Select all that apply.)
a. Eye contact promotes nonverbal communication. b. Nurses should foster assimilation and conformity to the dominant culture. c. Reading about practices of various cultures will ensure cultural competence. d. The ability to work within a patient's cultural context requires ongoing effort. e. Self-examination of attitudes toward various cultures promotes competent care.
A female client receiving methotrexate for the treatment of rheumatoid arthritis is given a prescription for trimethoprim and sulfamethoxazole (Bactrim DS). The client returns to the physician's office feeling worse than before
She now has a cough and unusual bruising on the extremities. The physician orders a complete blood count and a complete metabolic profile. Which test results would the nurse expect to find? Select all that apply. A) Increased hemoglobin B) Decreased number of white blood cells C) Increased number of red blood cells D) Decreased number of platelets E) All values should be within normal limits
With an intact oculocephalic reflex, the
a. patient's eyes move in the same direction the head is turned. b. patient's eyes move in the opposite direction to the movement of the patient's head. c. patient's eyes remain midline. d. doll's eye reflex is absent.
What are some of the current issues creating conflict related to nursing?
A. Budget constraints do not allow increases in nursing salaries. B. There is increased specialization by professional nurses. C. Nurse staffing has decreased while unlicensed assistive personnel have increased. D. Nurses as educated professionals are demanding a share in decision making. E. Signing bonuses and recruiting new graduates are used to maintain nursing staff. F. Third-party reimbursement is available for advanced practice nurses.