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 C

Explanation

Referred pain is pain that is felt in a location different from its source due to shared nerve pathways or central nervous system processing. A client who has pancreatitis may experience pain in the left shoulder due to irritation of the diaphragm by pancreatic enzymes or inflammation. This pain is referred from the abdominal cavity to the shoulder through the phrenic nerve.

A client who has peritonitis reports generalized abdominal pain that corresponds to the site of inflammation and infection in the peritoneum. A client who has angina reports substernal chest pain that reflects the ischemia and hypoxia of the myocardium. A client who is postoperative reports incisional pain that is caused by tissue damage and inflammation at the surgical site.

A. "Tell me why it's important to have your CD4+ count checked." B. "Name a few things you will change about your diet." C. "List some ways you can cope with the stress of your illness." D. "Describe your daily medication schedule."

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.

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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 assessing the pain status of a group of clients. Which of the following findings indicates a client is experiencing referred pain?

Correct Answer is C

Explanation

A nurse is providing discharge teaching for a client who has HIV. Which of the following information is the priority for the nurse to review with the client?

Correct Answer is D

Explanation

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

A nurse is preparing to assist the provider with a thoracentesis for a client who has a left pleural effusion. Which of the following interventions is the priority for the nurse?

A nurse is preparing to discharge a client who has a halo device and is reviewing new prescriptions from the provider. The nurse should clarify which of the following prescriptions with the provider?

A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?

A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?

A nurse is teaching a group of clients who have cancer about radiation therapy. Which of the following activities should the nurse include in the teaching?