Author Question: During the emergent phase of burn care, which assessment will be most useful in determining whether ... (Read 42 times)

chandani · **on:** Jun 25, 2018

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

a. Check skin turgor.
b. Monitor daily weight.
c. Assess mucous membranes.
d. Measure hourly urine output.

Question 2

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

a. Encourage the patient to cough and auscultate the lungs again.
b. Notify the health care provider and prepare for endotracheal intubation.
c. Document the results and continue to monitor the patient's respiratory rate.
d. Reposition the patient in high-Fowler's position and reassess breath sounds.

Awesome · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

Answer to Question 2

ANS: B
The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.