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

A mastectomy is a surgical removal of one or both breasts, usually done to treat breast cancer. The nurse should respect the client's autonomy and provide factual information about the procedure, its benefits and risks, and possible alternatives . The nurse should also assess the client's readiness to learn, address any concerns or fears, and offer emotional support . Telling the client to get a second opinion may imply that the nurse does not trust the surgeon or doubts the necessity of the procedure.

Telling the client that they will be cancer-free if they have the procedure may be false or misleading, as there may be residual cancer cells or recurrence after surgery. Giving the client a list of other people who had the same procedure may violate confidentiality and may not be helpful or relevant to the client's situation.

A. Increase the client's fluid intake. B. Check the client's urine output. C. Reposition the client in bed. D. Administer PRN pain medication.

Correct Answer is B

Explanation

Continuous bladder irrigation (CBI) is a procedure that involves instilling sterile fluid into the bladder through a three-way catheter to prevent clot formation and maintain patency after a TURP surgery. The nurse should monitor the client's urine output closely and report any signs of obstruction such as decreased urine flow, blood clots, or abdominal pain.

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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

A nurse is caring for a client who is scheduled for a mastectomy. The client tells the nurse, "I'm not sure I want to have a mastectomy." Which of the following statements should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP). The client reports sharp lower abdominal pain. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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