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 A

Explanation

Choice A reason: Elevated creatinine is a hallmark of chronic kidney disease, reflecting reduced glomerular filtration rate. This aligns with renal function assessment, making it the correct finding the nurse would expect in a client with chronic kidney disease based on laboratory results.

Choice B reason: Decreased hemoglobin may occur in chronic kidney disease due to anemia, but it’s less specific than elevated creatinine, a direct renal marker. This is incorrect, as it’s secondary to the nurse’s primary expectation of creatinine elevation in kidney disease.

Choice C reason: Decreased red blood cell count accompanies anemia in kidney disease but is less direct than creatinine, which measures kidney function. This is incorrect, as it’s not the primary finding the nurse would expect compared to elevated creatinine levels.

Choice D reason: Increased white blood cells in urine suggest infection, not a universal finding in chronic kidney disease. Elevated creatinine is more consistent, making this incorrect, as it’s not the nurse’s primary expected lab result in kidney disease assessment.

A. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution. B. Checking IV access for blood return after the infusion. C. Pushing the drug as a bolus slowly over 5 minutes. D. Initiating the IV in a hand vein for rapid access. E. Keeping the client NPO during drug treatment. F. Using an IV controller to deliver the drug.

Correct Answer is ["B","F"]

Explanation

Choice A reason: Potassium concentration should be 10-20 mEq/100mL, not 1 mEq/10mL, to avoid irritation. Using an IV controller is correct, making this incorrect, as it’s an unsafe dilution compared to the nurse’s best practices for safe parenteral potassium administration.

Choice B reason: Checking IV access for blood return post-infusion ensures the potassium was delivered correctly, preventing extravasation. This aligns with IV therapy safety, making it a correct best practice the nurse should follow when administering parenteral potassium to the client.

Choice C reason: Pushing potassium as a bolus is dangerous, risking cardiac arrhythmias; it must be infused slowly. IV controller use is correct, making this incorrect, as it’s unsafe compared to the nurse’s best practices for administering potassium to a hypokalemic client.

Choice D reason: Hand veins are unsuitable for potassium, which is irritating and requires larger veins. Checking blood return is correct, making this incorrect, as it risks complications compared to the nurse’s best practices for safe potassium administration in the client.

Choice E reason: Keeping the client NPO is unnecessary for potassium administration, which addresses hypokalemia, not digestion. IV controller use is correct, making this incorrect, as it’s irrelevant to the nurse’s best practices for delivering parenteral potassium safely to the client.

Choice F reason: Using an IV controller ensures a safe, steady infusion rate for potassium, preventing cardiac complications. This aligns with medication safety protocols, making it a correct best practice the nurse should employ when administering parenteral potassium to the hypokalemic 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

The nurse is reviewing a client’s record and notes that the primary health care provider has documented that the client has chronic kidney disease. On review of the laboratory results, the nurse most likely would expect to note which finding?

Correct Answer is A

Explanation

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

Correct Answer is ["B","F"]

Explanation

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