Showing posts with label Skin and Integumentary Diseases. Show all posts

A male client with psoriasis visits the dermatology clinic. When inspecting the affected areas, the nurse expects to see which type of secondary lesion.. Scale

A male client with psoriasis visits the dermatology clinic.

When inspecting the affected areas, the nurse expects to see which type of secondary lesion?

A. Scale
B. Crust
C. Ulcer
D. Scar

The correct answer is: A- Scale

Psoriasis is a chronic autoimmune disease characterized by patches of thick, red, scaly skin. The primary lesions in psoriasis are plaques, which are raised, inflamed patches of skin. The secondary lesions that often develop are:

Scales: These are flaky patches of skin that form on top of the plaques. They are often silvery or white in color.
Crusts: These are hardened, dried-out scales that can form on top of the plaques.
Fissures: These are painful cracks in the skin that can develop in severe cases of psoriasis.
Erythema: This is redness of the skin.

While crusts can sometimes form in psoriasis, the most common secondary lesion is scales.

Psoriasis: Understanding the Condition and Its Secondary Lesions

Psoriasis is a chronic autoimmune disease that affects the skin, causing it to become inflamed, thickened, and covered in silvery scales. While the exact cause of psoriasis is unknown, it is believed to be due to an overactive immune system.

Primary and Secondary Lesions:

The primary lesions in psoriasis are plaques, which are raised, inflamed patches of skin. These plaques are often covered in scales, which are flaky patches of skin that can be silvery or white in color.

Secondary lesions can develop in psoriasis as a result of scratching, picking, or infection. These secondary lesions may include:

Crusts: These are hardened, dried-out scales that can form on top of the plaques.
Fissures: These are painful cracks in the skin that can develop in severe cases of psoriasis.
Erythema: This is redness of the skin.
Excoriation: This is damage to the skin caused by scratching.
Hyperkeratosis: This is thickening of the outermost layer of the skin.
Koebner phenomenon: This is the development of new psoriasis lesions at sites of injury.

Factors that can Worsen Psoriasis:

Several factors can worsen psoriasis, including:

Stress: Emotional stress can trigger or worsen psoriasis flare-ups.
Injuries: Injuries to the skin can cause new psoriasis lesions to develop.
Infections: Infections, such as strep throat or tonsillitis, can trigger psoriasis flare-ups.
Medications: Certain medications, such as beta-blockers and nonsteroidal anti-inflammatory drugs (NSAIDs), can worsen psoriasis.
Weather: Dry weather can worsen psoriasis symptoms, while warm, humid weather may improve them.

Treatment for Psoriasis:

While there is no cure for psoriasis, there are several treatments available to help manage the symptoms. These may include:

Topical medications: These are creams or ointments that are applied directly to the affected skin.
Light therapy: This involves exposing the affected skin to ultraviolet light.
Systemic medications: These are oral or injectable medications that work to suppress the immune system.

It is important to see a dermatologist if you have any concerns about psoriasis. A dermatologist can diagnose the condition and recommend the best treatment for you.

Nurse Rudolf documents the presence of a scab on a client’s deep wound.

The nurse identifies this as which phase of wound healing?

A- Inflammatory
B- Migratory
C- Proliferative
D- Maturation

Answer B.

The scab formation is found in the migratory phase.
It is accompanied by migration of epithelial cells, synthesis of scar tissue by fibroblasts, and development of new cells that grow across the wound.
In the inflammatory phase, a blood clot forms, epidermis thickens, and an inflammatory reaction occurs in the subcutaneous tissue.
During the proliferative phase, the actions of the migratory phase continue and intensify, and granulation tissue fills the wound.
In the maturation phase, cells and vessels return to normal and the scab sloughs off.

Here's a deeper dive into the fascinating world of wound healing, focusing on the migratory phase and scab formation:

The Migratory Phase: A Cellular Orchestra

Imagine a complex dance where different cell types work together to heal a wound. The migratory phase is exactly that. Here's what happens:

Epithelial Cells on the Move: These are the building blocks of your skin. When a wound occurs, nearby healthy epithelial cells get activated and start migrating inwards, like a living bridge, to cover the exposed area.
Fibroblasts Get Busy: Underneath the migrating epithelial cells, fibroblasts become the workhorses. They churn out collagen, a protein that forms the foundation of scar tissue, providing strength and structure to the healing wound.
Scab Formation: A Protective Shell: As the epithelial cells migrate and the underlying area fills with collagen, a scab starts to form. This scab is essentially dried blood plasma, fibrin (a clotting protein), and dead cells. It acts as a protective cover, shielding the delicate new tissue beneath from infection, dehydration, and external damage.

Beyond the Basics: Factors Affecting Scab Formation

Several factors influence scab formation and the overall healing process:

Wound Depth and Size: Deeper wounds take longer to heal and may form thicker scabs. Larger wounds also require more extensive cellular migration and collagen production.
Blood Supply: Good blood flow delivers vital oxygen and nutrients to the wound bed, facilitating cell migration and tissue growth. Poor circulation can delay healing and scab formation.
Infection: If bacteria invade the wound, the body's immune response goes into overdrive, potentially delaying scab formation and prolonging healing.
Moisture Balance: Keeping the wound moist promotes cell migration and tissue growth. Conversely, a dry wound creates a barrier to migration and can lead to a harder, less flexible scab.

Remember:

Scab formation is a natural part of healing, but it's important not to pick at it. Picking can disrupt the delicate new tissue underneath and increase the risk of scarring or infection. Let the scab fall off naturally as the healing progresses.

A female client sees a dermatologist for a skin problem.

Later, the nurse reviews the client’s chart and notes that the chief complaint was intertrigo.
This term refers to which condition?

A- Spontaneously occurring wheals
B- A fungus that enters the skin’s surface, causing infection
C- Inflammation of a hair follicle
D- Irritation of opposing skin surfaces caused by friction

The correct answer is: D- Irritation of opposing skin surfaces caused by friction.

Here's why:

Intertrigo describes a skin condition that develops when two skin surfaces rub together frequently, causing irritation and inflammation. This commonly occurs in skin folds like the groin, armpits, under the breasts, and between the buttocks.

A. Spontaneously occurring wheals:

This describes a symptom, not a specific condition. It could be related to various conditions, including hives or allergic reactions.

B. A fungus that enters the skin's surface, causing infection:

This describes a fungal infection, not specifically intertrigo. While intertrigo can sometimes be complicated by a secondary fungal infection, it's not the defining characteristic.

C. Inflammation of a hair follicle:

This describes folliculitis, which refers to inflammation of the hair follicle, not intertrigo.

Therefore, based on the definition of intertrigo, D accurately reflects the skin condition described by the chief complaint in this scenario.

Which nursing intervention can help a client maintain healthy skin?

A- Keep the client well hydrated.
B- Avoid bathing the client with mild soap.
C- Remove adhesive tape quickly from the skin.
D- Recommend wearing tight-fitting clothes in hot weather.

Out of the listed options, the most effective nursing intervention for maintaining healthy skin is: A. Keep the client well hydrated.

Here's why:

- Proper hydration:

Drinking adequate water throughout the day helps keep the skin plump and elastic, preventing dryness and wrinkles. It also flushes toxins out of the body, contributing to overall skin health.

- Mild soap:

While avoiding harsh soaps or detergents is important, using mild soap for bathing is still necessary for hygiene and preventing infections.

- Quick removal of adhesive tape:

While quick removal can be helpful to minimize discomfort, it can also irritate and damage the skin. Using a removal technique with oil or barrier film beforehand is recommended.

- Tight clothes:

Wearing tight-fitting clothes in hot weather can trap heat and moisture against the skin, leading to irritation and potentially increasing the risk of infections.

Therefore, while all options have some merit for maintaining healthy skin, adequate hydration is the most fundamental and impactful intervention for overall skin health and well-being.

Additional Nursing Interventions:

Additional nursing interventions for healthy skin include:

- Promoting good nutrition:

A balanced diet rich in vitamins and minerals, especially A, C, and E, supports skin health and healing.

- Encouraging sun protection:

Using sunscreen with SPF 30 or higher daily helps prevent sun damage and premature aging.

- Moisturizing the skin:

Regularly applying moisturizer helps keep the skin hydrated and supple, especially after bathing.

- Maintaining good hygiene:

Washing hands frequently and keeping the skin clean reduces the risk of infections.

- Avoiding smoking and excessive alcohol:

These habits can contribute to dry, wrinkled, and unhealthy skin.

By incorporating these interventions into client care, nurses can play a crucial role in promoting and maintaining healthy skin for their patients and clients.

The nurse is teaching a female client with a leg ulcer about tissue repair and wound healing.

Which of the following statements by the client indicates effective teaching?

a- “I’ll limit my intake of protein.”
b- “I’ll make sure that the bandage is wrapped tightly.”
c- “My foot should feel cold.”
d- “I’ll eat plenty of fruits and vegetables.”

Answer D.

For effective tissue healing, adequate intake of protein, vitamin A, B complex, C, D, E, and K are needed.
Therefore, the client should eat a high protein diet with plenty of fruits and vegetables to provide these nutrients.
The bandage should be secure but not too tight to impede circulation to the area (needed for tissue repair).
If the client’s foot feels cold, circulation is impaired, thus inhibiting.

The correct answer is d- “I’ll eat plenty of fruits and vegetables.”

This statement indicates that the client has understood the importance of nutrition for wound healing. Fruits and vegetables are rich in vitamins and minerals that are essential for tissue repair. They also contain antioxidants that help to protect cells from damage.

The other statements are incorrect.

- Statement a:

Limiting protein intake can actually hinder wound healing, as protein is essential for building new tissue.

- Statement b:

Wrapping the bandage too tightly can restrict blood flow to the area and impede healing.

- Statement c:

A cool foot does not necessarily indicate that the wound is healing properly. In fact, a warm foot is often a sign of good blood flow and healing.

Therefore, the client's statement about eating fruits and vegetables is the best indicator that she has understood the nurse's teaching about tissue repair and wound healing.

In a female client with burns on the legs, which nursing intervention helps prevent contractures?

a- Applying knee splints.
b- Elevating the foot of the bed.
c- Hyperextending the client’s palms.
d- Performing shoulder range-of-motion exercises.

Answer A.

Applying knee splints prevents leg contractures by holding the joints in a position of function.
Elevating the foot of the bed can’t prevent contractures because this action doesn’t hold the joints in a position of function.
Hyperextending a body part for an extended time is inappropriate because it can cause contractures.
Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

In a female client with burns on the legs, the most helpful nursing intervention to prevent contractures is:

c. Hyperextending the client's palms.

Here's why:

a. Applying knee splints helps with positioning but doesn't actively address contracture prevention.
b. Elevating the foot of the bed may help with edema but doesn't specifically prevent contractures.
d. Performing shoulder range-of-motion exercises are important for overall mobility but not directly relevant to preventing leg contractures.

splinting in abduction:

Hyperextending the client's palms is a technique called "splinting in abduction" which helps prevent contractures of the flexor muscles in the arms. This indirectly helps prevent contractures in the legs by promoting a balanced posture and preventing the client from adopting a flexed position that could lead to leg contractures.

prevention in burn patients:

It's important to note that contracture prevention in burn patients requires a comprehensive approach that includes various interventions like early mobilization, splinting, pressure garments, and scar management. Hyperextending the palms is just one piece of the puzzle, but it can be a valuable tool in specific situations.

nursing intervention:

Remember, choosing the most appropriate nursing intervention always depends on the individual patient's needs and the specific burn characteristics. Consultation with a qualified healthcare professional is crucial for optimal burn care and contracture prevention.

A female adult client with atopic dermatitis is prescribed a potent topical corticosteroid, to be covered with an occlusive dressing.

To address a potential client problem associated with this treatment, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement, the nurse should add which “related-to” phrase?

a- Related to potential interactions between the topical corticosteroid and other prescribed drugs.
b- Related to vasodilatory effects of the topical corticosteroid.
c- Related to percutaneous absorption of the topical corticosteroid.
d- Related to topical corticosteroid application to the face, neck, and intertriginous sites.

Answer C.

A potent topical corticosteroid may increase the client’s risk for injury because it may be absorbed percutaneously, causing the same adverse effects as systemic corticosteroids. Topical corticosteroids aren’t involved in significant drug interactions.
These preparations cause vasoconstriction, not vasodilation. A potent topical corticosteroid rarely is prescribed for use on the face, neck, or intertriginous sites because application on these areas may lead to increased adverse effects.

The answer is (c) Related to percutaneous absorption of the topical corticosteroid.

Occlusive dressings increase the absorption of topical corticosteroids, which can lead to side effects such as skin atrophy, striae, and telangiectasia. These side effects are more likely to occur with potent topical corticosteroids and with long-term use.

The other answer choices are incorrect because:

(a) Related to potential interactions between the topical corticosteroid and other prescribed drugs is not a potential client problem associated with this treatment.
(b) Related to vasodilatory effects of the topical corticosteroid is not a potential client problem associated with this treatment.
(d) Related to topical corticosteroid application to the face, neck, and intertriginous sites is a potential client problem associated with this treatment, but it is not the most specific “related-to” phrase.

Therefore, the most specific and accurate “related-to” phrase is (c) Related to percutaneous absorption of the topical corticosteroid.

The nurse is assessing for the presence of cyanosis in a male dark-skinned client.

The nurse understands that which body area would provide the best assessment?

a. Lips
b. Sacrum
c. Earlobes
d. Back of the hands

Answer A.

In a dark-skinned client, the nurse examines the lips, tongue, nail beds, conjunctivae, and palms of the hands and soles of the feet at regular intervals for subtle color changes.

In a client with cyanosis, the lips and tongue are gray; the palms, soles, conjunctivae, and nail beds have a bluish tinge.

Nurse Bea plans to administer dexamethasone cream to a client who has dermatitis over the anterior chest How should the nurse apply this topical agent?

a- With a circular motion, to enhance absorption

b- With an upward motion, to increase blood supply to the affected area

c- In long, even, outward, and downward strokes in the direction of hair growth

d- In long, even, outward, and upward strokes in the direction opposite hair growth

Answer C.
When applying a topical agent, the nurse should begin at the midline and use long, even, outward, and downward strokes in the direction of hair growth.
This application pattern reduces the risk of follicle irritation and skin inflammation.

How to administer dexamethasone?

Dexamethasone was administered orally (in liquid or tablet form) or intravenously, 6 mg once daily for 10 days.

Why administer dexamethasone?

During surgery, dexamethasone is given to the patient to reduce the risk of post-operative nausea and vomiting, to relieve pain, and to make the patient feel better. However, it is not known if this treatment, in the short term, causes undesirable side effects.

How to apply betamethasone cream?

Instructions for use and dosage of the drug BETAMETHASONE BIOGARAN cream. Spread the cream on the lesions and make it penetrate with a light massage. To treat large areas of skin, apply sparingly, then blend until completely

How to administer corticosteroids?

Corticosteroids should be taken in the morning; in very severe flare-ups, it may be necessary to administer the treatment in two doses, morning and evening, at the start of the treatment.

What is the role of dexamethasone?

Dexamethasone: Mechanism of Action

Synthetic corticosteroids, including dexamethasone, are used primarily for their anti-inflammatory effect. In high doses, they reduce the immune response. Their metabolic and sodium retention effect is less than that of hydrocortisone.

What are the effects of cortisone ointment?

Applying topical corticosteroids to the thighs and chest (in women) for long periods can induce stretch marks. Similarly, pregnant women with atopic dermatitis should carefully apply topical corticosteroids to the abdomen to avoid the risk of stretch marks.

How to apply a cortisone cream?

Apply widely

We apply on the red patches by going frankly. You have to put the cream overflowing even a little from the inflamed areas: make large gestures with your palm to cover them well, rather than applying with your fingertip in a dotted line.

How to apply an ointment on the skin?

To do this, heat the cream between your hands. Start by applying it to the center of the face and especially on the cheeks, an area that is often dry. Go up towards the outside of the face gently by exerting two to three pressures with the palms of your hands.

Why use betamethasone cream?

What is this medicine for? BETAMETHASONE BIOGARAN is intended for cutaneous use only. This drug is a local corticosteroid of strong activity. It is recommended in certain skin diseases such as contact eczema, atopic dermatitis, psoriasis, but your doctor can prescribe it in other cases.

When to administer dexamethasone?

Dexamethasone should be taken with a meal or snack according to the schedule established by your doctor (1 to 4 times a day). The last dose of the day should be taken before 5 p.m.

How to dilute dexamethasone?

This solution can be diluted in a solution of sodium chloride or glucose. I.V. OR I.M. INJECTIONS The initial dosage can vary from 2 to 20 mg/d, depending on the type of disease to be treated.

What is dexamethasone injection?

Dexamethasone Inj. is indicated in the treatment of allergic reactions, myoglobinuria, toxaemia, shock, stress and urticaria. Local treatment of arthritis, bursitis, distortions, periarthritis, tendinitis and tenosynovitis.

While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge.. All family members will need to be treated

While in a skilled nursing facility, a male client contracted scabies, which is diagnosed the day after discharge.

The client is living at her daughter’s home, where six other persons are living.

During her visit to the clinic, she asks a staff nurse, “What should my family do?” The most accurate response from the nurse is:

a- “All family members will need to be treated.”

b- “If someone develops symptoms, tell him to see a physician right away.”

c- “Just be careful not to share linens and towels with family members.”

d- “After you’re treated, family members won’t be at risk for contracting scabies.”

Answer A.

When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he’s symptomatic or not.

Towels and linens should be washed in hot water.
Scabies can be transmitted from one person to another before symptoms develop.

A male client visits the physician’s office for treatment of a skin disorder. As a primary treatment, the nurse expects the physician to prescribe.. a topical agent

A male client visits the physician’s office for treatment of a skin disorder.
As a primary treatment, the nurse expects the physician to prescribe:

a- an I.V. corticosteroid.

b- an I.V. antibiotic.

c- an oral antibiotic.

d- a topical agent.

Answer D.

Although many drugs are used to treat skin disorders, topical agents — not I.V. or oral agents - are the mainstay of treatment.

A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake. The nurse should inform the client that this drug may cause.. diarrhea

A female client with herpes zoster is prescribed acyclovir (Zovirax), 200 mg P.O. every 4 hours while awake.
The nurse should inform the client that this drug may cause:

a- palpitations.

b- dizziness.

c- diarrhea.

d- metallic taste.

Answer C.

Oral acyclovir may cause such adverse GI effects as diarrhea, nausea, and vomiting.
It isn’t associated with palpitations, dizziness, or a metallic taste.

When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care.. Administering systemic antibiotics as prescribed

When caring for a male client with severe impetigo, the nurse should include which intervention in the plan of care?

a- Placing mitts on the client’s hands

b- Administering systemic antibiotics as prescribed

c- Applying topical antibiotics as prescribed

d- Continuing to administer antibiotics for 21 days as prescribed

Answer B.

Impetigo is a contagious, superficial skin infection caused by beta-hemolytic streptococci. If the condition is severe, the physician typically prescribes systemic antibiotics for 7 to 10 days to prevent glomerulonephritis, a dangerous complication.

The client’s nails should be kept trimmed to avoid scratching; however, mitts aren’t necessary.

Topical antibiotics are less effective than systemic antibiotics in treating impetigo.

pain management.. A male client with a solar burn of the chest, back, face, and arms is seen in urgent care

A male client with a solar burn of the chest, back, face, and arms is seen in urgent care.

The nurse’s primary concern should be:

a- fluid resuscitation.

b- infection.

c- body image.

d- pain management.

Answer D. With a superficial partial thickness burn such as a solar burn (sunburn), the nurse’s main concern is pain management.
Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers.
Body image disturbance is a concern that has lower priority than pain management.

A female client with second- and third-degree burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises.. dislodge the autografts

A female client with second- and third-degree burns on the arms receives autografts.

Two days later, the nurse finds the client doing arm exercises.
The nurse knows that this client should avoid exercise because it may:

a- dislodge the autografts.

b- increase edema in the arms.

c- increase the amount of scarring.

d- decrease circulation to the fingers.

Answer A.
Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position.
None of the other options results from exercise.

The clinic nurse assesses the skin of a white characteristic is associated with this skin disorder.. Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions

The clinic nurse assesses the skin of a white characteristic is associated with this skin disorder?

a- Clear, thin nail beds

b- Red-purplish scaly lesions

c- Oily skin and no episodes of pruritus

d- Silvery-white scaly patches on the scalp, elbow, knees, and sacral regions

Answer D.
Cellulitis is a skin infection into deeper dermal and subcutaneous tissues that results in a deep red erythema without sharp borders and spreads widely throughout tissue spaces.
Warm compresses may be used to decrease the discomfort, erythema, and edema.
After tissue and blood cultures are obtained, antibiotics will be initiated.
The nurse should provide supportive care as prescribed to manage symptoms such as fatigue, fever, chills, headache, and myalgia.
Heat lamps can cause more disruption to already inflamed tissue.
Cold compresses and alternating cold and hot compresses are not the best measures.

A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions.. Net-like appearance

A nurse is reviewing the medical record of a male client to be admitted to the nursing unit and notes documentation of reticular skin lesions.

The nurse expects that these lesions will appear to be:

a- Ring-shaped

b- Linear

c- Shaped like an arc

d- Net-like appearance

Answer D.
Reticular skin lesions resemble a net in appearance.
Annular lesions are ring-shaped, whereas linear lesions appear in a straight line.
Arciform lesions are shaped like an arc.

A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own. To help the client avoid pressure ulcers, the nurse should.. turn him frequently

A male client who has suffered a cerebrovascular accident (CVA) is too weak to move on his own.

To help the client avoid pressure ulcers, the nurse should:

a- turn him frequently.

b- perform passive range-of-motion (ROM) exercises.

c- reduce the client’s fluid intake.

d- encourage the client to use a footboard.

Answer A.
The most important intervention to prevent pressure ulcers is frequent position changes, which relieve pressure on the skin and underlying tissues.
If pressure isn’t relieved, capillaries become occluded, reducing circulation and oxygenation of the tissues and resulting in cell death and ulcer formation.
During passive ROM exercises, the nurse moves each joint through its range of movement, which improves joint mobility and circulation to the affected area but doesn’t prevent pressure ulcers.
Adequate hydration is necessary to maintain healthy skin and ensure tissue repair.
A footboard prevents plantar flexion and footdrop by maintaining the foot in a dorsiflexed position.

When assessing a lesion diagnosed as malignant melanoma.. An irregular shaped lesion

When assessing a lesion diagnosed as malignant melanoma, the nurse in-charge most likely expects to note which of the following?

a- An irregular shaped lesion

b- A small papule with a dry, rough scale

c- A firm, nodular lesion topped with crust

d- A pearly papule with a central crater and a waxy border

Answer A.
A melanoma is an irregularly shaped pigmented papule or plaque with a red-, white-, or blue-toned color.
Basal cell carcinoma appears as a pearly papule with a central crater and rolled waxy border.
Squamous cell carcinoma is a firm, nodular lesion topped with a crust or a central area of ulceration.
Actinic keratosis, a premalignant lesion, appears as a small macule or papule with a dry, rough, adherent yellow or brown scale.

In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He’s in the burn unit receiving fluid resuscitation

In an industrial accident, a male client that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body.

He’s in the burn unit receiving fluid resuscitation.
Which observation shows that the fluid resuscitation is benefiting the client?

a- A urine output consistently above 100 ml/hour

b- A weight gain of 4 lb (2 kg) in 24 hours

c- Body temperature readings all within normal limits

d- An electrocardiogram (ECG) showing no arrhythmias

Answer A.
In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures.
If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour.
Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate.
Weight gain from fluid resuscitation isn’t a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing.
Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren’t primary indicators.