A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

Start intravenous fluids.

Start albumin.

Check the pulses with a Doppler device.

Calculate the rule of nines.

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting IV fluids is the first action to correct hypotension (72/48) and tachycardia (152) in burn shock, restoring perfusion. This aligns with burn resuscitation protocols, making it the correct action to address the client’s critical hypovolemia and absent pedal pulses immediately.

Choice B reason: Albumin is used later in burn management, not first, as crystalloids like saline restore volume. IV fluids address hypovolemia, making this incorrect, as it’s premature compared to the nurse’s priority of initiating fluid resuscitation in the burn-injured client.

Choice C reason: Checking pulses with Doppler assesses perfusion but delays fluid resuscitation needed for hypotension and shock. IV fluids are urgent, making this incorrect, as it’s secondary to the nurse’s first action of correcting hypovolemia in the burn client’s emergency care.

Choice D reason: Calculating the rule of nines guides fluid volume but is secondary to starting IV fluids for hypotension. Immediate resuscitation is critical, making this incorrect, as it delays the nurse’s priority of addressing the client’s shock state in the burn emergency.

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Correct Answer is C

Explanation

Choice A reason: Encouraging fluid intake is inappropriate post-hemodialysis, as fluid overload is a risk. A fever of 101.2°F requires provider notification, making this incorrect, as it’s unsafe compared to the nurse’s priority of addressing a potential infection promptly.

Choice B reason: Monitoring vital signs is useful but doesn’t address the urgency of a 101.2°F fever post-hemodialysis, which may indicate infection. Notifying the provider is critical, making this incorrect, as it delays the nurse’s action to manage a serious complication.

Choice C reason: Notifying the provider is most appropriate for a fever of 101.2°F post-hemodialysis, as it may signal infection, a serious complication. This aligns with post-dialysis care priorities, making it the correct action for the nurse to take immediately.

Choice D reason: Monitoring the shunt site is relevant but less urgent than notifying the provider about a fever, which may indicate systemic infection. This is incorrect, as it delays the nurse’s priority of addressing the client’s elevated temperature post-hemodialysis.

A. Increased urine output. B. Persistent diarrhea. C. Hypotension. D. Tachycardia.

Correct Answer is C

Explanation

Choice A reason: Increased urine output is not typical in untreated hypothyroidism, which slows metabolism and fluid balance. Hypotension from reduced cardiac output is expected, making this incorrect, as it doesn’t align with the nurse’s anticipated findings in a client non-compliant with hypothyroidism therapy.

Choice B reason: Persistent diarrhea is more associated with hyperthyroidism, not hypothyroidism, which causes constipation. Hypotension is a common finding in untreated hypothyroidism, making this incorrect, as it contradicts the expected symptoms in the nurse’s assessment of the non-compliant client.

Choice C reason: Hypotension is expected in untreated hypothyroidism due to decreased metabolic rate and cardiac output. This aligns with endocrine assessment findings, making it the correct finding the nurse would anticipate in a client who hasn’t taken thyroid replacement medication regularly.

Choice D reason: Tachycardia is typical in hyperthyroidism, not hypothyroidism, which causes bradycardia. Hypotension is more consistent with untreated hypothyroidism, making this incorrect, as it doesn’t reflect the slowed metabolism expected in the nurse’s evaluation of the non-compliant client.

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A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

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Naxlex Comprehensive Predictor Exams

A client with chronic kidney disease returns to the nursing unit following a hemodialysis treatment. On assessment, the nurse notes that the client’s temperature is 101.2°F (38.5°C). Which nursing action is most appropriate?

Correct Answer is C

Explanation

A home health nurse is assessing a client who requires lifelong replacement hormone therapy for hypothyroidism. The client has not been taking his medication regularly. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?

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Which client electrocardiography (ECG) change from baseline will alert the nurse to possible development of hypercalcemia?

Which assessments are most important for the nurse to perform to prevent harm on a client with a sodium level of 118 mEq/L (mmol/L)? (Select all that apply)