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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This response assesses the client's understanding and adherence to the antiretroviral therapy (ART), which isessential for managing HIV and preventing complications and transmission. ART requires strict adherence to a specific regimen of medications that must be taken at certain times and with certain foods or fluids.
Correct Answer is D
Explanation
The nurse should instruct the client to trim toenails straight across to prevent ingrown toenails and infection. The nurse should also advise the client to inspect the feet daily for any signs of injury or ulceration, to avoid applying lotion between the toes as this can cause maceration and fungal growth, and to avoid soaking the feet as this can dry out the skin and increase the risk of injury.
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