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 B

Explanation

Weight gain 1.1 kg (2.4 lb) in 24 hours indicates fluid retention and possible volume overload, which can worsen kidney function and cause complications such as hypertension, pulmonary edema, and heart failure. The nurse should report this finding to the provider and monitor the client's vital signs, fluid intake and output, and electrolyte levels.

Creatinine 0.8 mL/dL is within the normal range for adults and does not indicate kidney impairment. Peripheral pulses 2+ bilaterally are normal and do not suggest any vascular problems. Urine specific gravity 1.045 is slightly high but not abnormal for a client with acute kidney failure, as it reflects the reduced ability of the kidneys to dilute urine.

A. "Most clients feel better after taking the antibiotic." B. "Your provider wouldn't prescribe this medication if it weren't necessary." C. "I will tell your provider that you do not want to take this medication." D. "If you don't take this medication, you will feel worse."

Correct Answer is C

Explanation

B. This response educates the client about the importance of taking the prescribed medication and reinforces the authority and expertise of the provider. However, it does not respect the client's autonomy to make independent healthcare decisions

C.This response acknowledges that the client has reservations about the antibiotics and offers to communicate this to the healthcare provider for further intervention.

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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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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