INTRODUCTION TO CRITICAL CARE NURSING 7TH EDITION SOLE TEST BANK
Chapter 21: Burns Sole: Introduction to Critical Care Nursing, 7th Edition MULTIPLE CHOICE 1. The optimal measurement of intravascular fluid status during the immediate fluid resuscitation phase of burn treatment is a. blood urea nitrogen. b. daily weight. c. hourly intake and urine output. d. serum potassium. ANS: C During initial fluid resuscitation, urine output helps guide fluid resuscitation needs. Measuring hourly intake and output is most effective in determining the needs for additional fluid infusion than is urine output alone. Blood urea nitrogen may be used to monitor volume status, but it is affected by the hypermetabolic state seen after burns, so it is not the optimal measure of intravascular fluid status. Daily weight measures overall volume status, not just intravascular volume. Serum potassium is released with tissue damage and thus is not the optimum measure of intravascular fluid status. DIF: Cognitive Level: Remember/Knowledge REF: Box 21-1 OBJ: Discuss the primary and secondary survey assessments during resuscitation and the acute phases of burn management. TOP: Nursing Process Step: Assessment MSC: NCLEX Client Needs Category: Physiological Integrity NURSINGTB.COM
2. In patients with extensive burns, edema occurs in both burned and unburned areas because of a. catecholamine-induced vasoconstriction. b. decreased glomerular filtration. c. increased capillary permeability. d. loss of integument barrier. ANS: C Capillary permeability is altered in burns beyond the area of tissue damage, resulting in significant shift of proteins, fluid, and electrolytes resulting in edema (third-spacing). Catecholamine-induced vasoconstriction does not produce edema. Decreased glomerular filtration may cause fluid retention, but it is not responsible for the extensive edema seen after burn injury. Loss of integument barrier does not cause edema. DIF: Cognitive Level: Remember/Knowledge REF: p. 592 | Table 21-4 OBJ: Describe the pathophysiology of burns. TOP: Nursing Process Step: Evaluation MSC: NCLEX Client Needs Category: Physiological Integrity 3. Tissue damage from burn injury activates an inflammatory response that increases the patient’s risk for a. acute kidney injury. b. acute respiratory distress syndrome.
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