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
Wear a lead apron when providing client care. Internal radiation therapy (brachytherapy) is a type of treatment that uses a radioactive source placed inside or near the tumor . The nurse should wear a lead apron to protect themselves from exposure to radiation when caring for the client. The other actions are not appropriate for a client receiving internal radiation therapy.
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.
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