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

The priority intervention for the nurse is to determine whether the client has an allergy to local anesthetics, as this could cause a serious adverse reaction during the procedure.

Thoracentesis is a minimally invasive procedure that involves inserting a needle into the pleural space to drain excess fluid or air from around the lungs. The procedure requires local anesthesia to numb the area where the needle is inserted. Therefore, it is essential to assess for any allergy to local anesthetics before proceeding with the procedure.

A. Apply an ice pack to the client's knee. B. Place pillows under the client's knee. C. Gently massage the area around the client's incision. D. Perform range-of-motion exercises to the client's knee.

Correct Answer is A

Explanation

Applying an ice pack to the client's knee can help reduce inflammation, swelling, and pain after a total knee arthroplasty. The nurse should avoid placing pillows under the client's knee, as this can cause flexion contractures and impair mobility and healing. Massaging or manipulating the incision site can increase pain and risk of infection or bleeding. Range-of-motion exercises are important for recovery, but they should be done with caution and under supervision, not when the client is experiencing severe 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 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?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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