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 D

Explanation

Positive end-expiratory pressure (PEEP) is a mode of mechanical ventilation that maintains a positive pressure in the airways at the end of expiration, preventing alveolar collapse and improving oxygenation. PEEP does not affect tidal volume, inspiratory pressure, or ventilation rate, which are determined by other ventilator settings.

A. Position the mouthpiece 2.5 cm (1 in) from the mouth. B. Exhale slowly through pursed lips. C. Hold breaths about 3 to 5 seconds before exhaling. D. Place hands on the upper abdomen during inhalation.

Correct Answer is C

Explanation

An incentive spirometer is a device that helps improve lung function by encouraging deep breathing and preventing atelectasis (collapse of alveoli) after surgery or prolonged bed rest. The client should position the mouthpiece firmly in their mouth, inhale deeply and slowly through the mouthpiece until the indicator reaches the desired level, hold their breath for 3 to 5 seconds, and then exhale normally through their nose or mouth.

Exhaling slowly through pursed lips or placing hands on the upper abdomen are techniques that can help with dyspnea (shortness of breath), but are not part of using an incentive spirometer. Positioning the mouthpiece 2.5 cm.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is checking a client's ventilator settings. The nurse should understand that positive end- expiratory pressure has which of the following purposes?

Correct Answer is D

Explanation

A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

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