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Exam NCLEX-RN topic 2 question 88 discussion

Actual exam question from Test Prep's NCLEX-RN
Question #: 88
Topic #: 2
[All NCLEX-RN Questions]

A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?

  • A. Fluid volume deficit
  • B. Fluid volume excess
  • C. Decreased cardiac output
  • D. Severe hypotension
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Suggested Answer: B 🗳️
(A) Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. (B) Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. (C) Increased cardiac output results as fluids shift back to the vascular compartment. (D)
Hypertension is the result of hypervolemia.

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