A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?
Answer(s): B
(A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D) Hypertension is the result of hypervolemia.
During a client's first postpartum day, the nurse assessed that the fundus was located laterally to the umbilicus.This may be due to:
Answer(s): D
(A, B) Endometritis, urine retention, or bladder distention provide good distractors because they may delay involution but do not usually cause the uterus to be lateral. (C) Bowel distention and constipation are common in the postpartum period but do not displace the uterus laterally. (D) Urine retention or bladder distention commonly displaces the uterus to the right and may delay involution.
Post your Comments and Discuss NCLEX NCLEX-RN exam with other Community members:
Naveen Ahlam commented on November 29, 2024 Great stuff Anonymous upvote
Isadora Guimarães commented on November 10, 2024 Very good to study UNITED STATES upvote
Marydee commented on April 02, 2020 Just purchased, will see if it is the real deal. Will give a further update later! Anonymous upvote
Our website is free, but we have to fight against bots and content theft. We're sorry for the inconvenience caused by these security measures. You can access the rest of the NCLEX-RN content, but please register or login to continue.