A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

Urine output 45 mL/hr

Potassium 5.2 mEq/L

Capillary refill 1.5 seconds

PaCO2 37 mm Hg

Answer and Explanation

The Correct Answer is B

This indicates hyperkalemia, which is a common complication of severe burn injuries due to massive cell destruction and fluid loss from damaged tissues. Hyperkalemia can lead to cardiac dysrhythmias and arrest, which are signs of hypovolemic shock.

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Correct Answer is A

Explanation

Confusion can be a sign of delirium, which is a common complication of immobility in older adults due to sensory deprivation, sleep disturbance, medication side effects, or dehydration. The nurse should assess for other causes of confusion, such as infection or hypoxia, and implement interventions to prevent or treat delirium.

A. History of Crohn's disease B. Diet high in fiber C. Age 46 years D. BMI of 24

Correct Answer is A

Explanation

A history of inflammatory bowel disease, such as Crohn's disease or ulcerative colitis, is a risk factor for colorectal cancer . These conditions cause chronic inflammation and damage to the cells lining the colon and rectum, which may increase the likelihood of DNA mutations and cancer development. A diet high in fiber may help lower the risk of colorectal cancer by promoting regular bowel movements and reducing exposure to toxins. Age 46 years is not a significant risk factor, as most cases of colorectal cancer occur in people older than 50. BMI of 24 is within the normal range and does not indicate obesity, which is another risk factor for colorectal cancer.

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A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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