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
DIF: Cognitive Level: Comprehension REF: p. 636
OB
...
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
DIF: Cognitive Level: Comprehension REF: p. 636
OBJ: Discuss the primary and secondary survey assessments during
resuscitation and the acute phases of burn management. TOP: Nursing
Process Step: Assessment
MSC: NCLEX: Physiological Integrity
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
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.
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). Catecholamineinduced
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: Comprehension REF: p. 626
OBJ: Describe the pathophysiology of burns.
TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity
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