The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)

distributive shock

cardiogenic shock

obstructive shock

hypovolemic shock

neurogenic shock

Answer and Explanation

Correct Answer : A,B

A. Distributive shock

Severe burns lead to systemic inflammatory response syndrome (SIRS), causing massive vasodilation, similar to septic shock (a type of distributive shock).

D. Hypovolemic shock

Fluid loss from burns leads to hypovolemic shock, which is the most common type of shock seen in burn patients.

B. Cardiogenic shock

Cardiogenic shock is caused by heart failure and is not a primary concern in burn injuries.

C. Obstructive shock

Obstructive shock (e.g., tension pneumothorax, cardiac tamponade) does not occur in burn patients unless another condition is present.

E. Neurogenic shock

Neurogenic shock occurs from spinal cord injuries, not burns.

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Correct Answer is C

Explanation

A. Diphenhydramine 50 mg PO
Diphenhydramine (Benadryl) treats mild allergic reactions but is not sufficient for anaphylaxis. The presence of SOB and angioedema suggests airway compromise, requiring epinephrine.

B. Famotidine 40 mg PO
Famotidine (H2 blocker) can help with allergic reactions but is not the priority in an emergency.

C. Epinephrine 1 mg IM
Epinephrine is the first-line treatment for anaphylaxis. It reverses airway swelling, hypotension, and bronchoconstriction. The standard IM dose is 0.3-0.5 mg, not 1 mg, but epinephrine remains the priority drug.

D. A fluid bolus of normal saline
IV fluids help treat hypotension in anaphylaxis, but epinephrine is the priority intervention.

A. Continue to monitor the client as a paralytic ileus is possible B. Administer the PRN stool softener to the client C. Obtain an order to insert a nasogastric tube set to low suction D. Report the assessment findings to the surgeon

Correct Answer is D

Explanation

A. Continue to monitor the client as a paralytic ileus is possible

Paralytic ileus can occur postoperatively, but sudden severe pain and distension indicate a more serious issue, such as bowel infarction.

B. Administer the PRN stool softener to the client

A stool softener is inappropriate if the client has a possible bowel obstruction or ischemia.

C. Obtain an order to insert a nasogastric tube set to low suction

An NG tube may help relieve distension, but it does not treat the underlying cause. The priority is to notify the surgeon.

D. Report the assessment findings to the surgeon

Absent bowel sounds, severe pain, and distension suggest bowel ischemia, a life-threatening complication requiring immediate surgical intervention.

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The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with SOB, wheezes, urticaria, itching and angioedema after receiving vancomycin IV. What is the priority nursing intervention after stopping the medication? Administer:

Correct Answer is C

Explanation

The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

Correct Answer is D

Explanation

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