Difficulty: Medium
Average Score: 75%
Simulated
Passage / Scenario
14-year-old adolescent admitted with a severe burn injury and shock, receiving IV fluid resuscitation therapy. Assessment findings: Temperature 36.5C, HR 122, Respirations 22, BP 108/68.A nurse is monitoring a 14 year old adolescent who was admitted with a severe burn injury and shock and is receiving IV fluid resuscitation therapy. Assessment findings: Temperature 36.5C, HR 122, Respirations 22, BP 108/68. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Correct answer
B
Rationale
The correct answer is B: Heart rate. In a patient with severe burn injury and shock, tachycardia (high heart rate) is a common sign of hypovolemia and inadequate tissue perfusion. As the patient receives adequate fluid resuscitation, their heart rate should gradually decrease towards normal range. Monitoring the heart rate is crucial in assessing the patient's response to fluid replacement therapy and overall hemodynamic stability. Choices A (BP), C (Weight), and D (Urine output) are important parameters to monitor in a patient receiving fluid resuscitation, but they do not directly reflect the adequacy of fluid replacement in the same way as heart rate does in this scenario.