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    Ati rn adult medical surgical 2023 proctored exam

    A nurse is assessing a client who has full-thickness burns. The nurse should identify that which of the following findings indicates the client's need for fluid resuscitation?

    Explanation & Rationale

    Rationale: A. Bilateral lung crackles: Bilateral lung crackles are typically a sign of fluid overload or pulmonary edema, not fluid loss. They do not indicate the need for fluid resuscitation in the case of burns. B. 1+ pitting peripheral edema:1+ pitting edema is mild and does not typically indicate the need for fluid resuscitation. It may occur with minor fluid retention, but it is not a severe indication of dehydration or fluid loss that would require resuscitation. C. Engorged neck veins: Engorged neck veins suggest fluid overload or venous congestion, often seen in conditions like heart failure, but not in the immediate need for fluid resuscitation for burn patients. D. Urine output 25 mL/hr: A urine output of 25 mL/hr is below the normal range (30 mL/hr or more) and suggests inadequate renal perfusion. This is a clear indicator that the client may require fluid resuscitation to restore adequate circulation and kidney function.

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