A client suffered a 45 percent total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action?

Administer a laxative per provider order

Prepare to insert a nasogastric (NG) tube

Document the findings

Obtain an abdominal xray

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering a laxative is contraindicated in the acute phase of a major burn where a paralytic ileus is suspected. Stimulating the bowel when it is functionally obstructed or non-motile can lead to severe abdominal cramping, vomiting, and a risk of aspiration in a critically ill patient.

Choice B reason: Major burns (> 20% TBSA) frequently result in a paralytic ileus due to the massive systemic inflammatory response and sympathetic nervous system activation, which shunts blood away from the GI tract. A nasogastric tube is essential to decompress the stomach, prevent gastric distention, and reduce the risk of vomiting and aspiration.

Choice C reason: While documentation is necessary, it is not a sufficient "action" when a patient exhibits signs of a paralytic ileus. The nurse must perform an intervention to mitigate the risks associated with gastric stasis and impending abdominal distention in a high-risk burn patient.

Choice D reason: An abdominal x-ray might confirm the presence of gas or distended bowel loops, but it does not treat the underlying issue. The priority is to decompress the gastrointestinal tract immediately to protect the airway and maintain patient comfort during the emergent phase of burn care.

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Correct Answer is A

Explanation

Choice A reason: Cardiogenic shock occurs when the heart’s muscular wall fails to pump effectively. A myocardial infarction (MI) causes necrosis of the cardiac tissue; if more than 40% of the left ventricle is damaged, the heart cannot maintain adequate cardiac output, leading directly to cardiogenic shock.

Choice B reason: A client with trauma-related blood loss is at risk for hypovolemic shock. This type of shock is caused by a lack of intravascular volume rather than a primary failure of the heart muscle itself, distinguishing it from the pump-failure mechanism of cardiogenic shock.

Choice C reason: A tension pneumothorax causes obstructive shock. The high pressure in the thoracic cavity shifts the mediastinum and compresses the great vessels (superior and inferior vena cava), physically preventing blood from returning to the heart, which is different from a primary muscular failure.

Choice D reason: A client with positive blood cultures is at risk for septic shock. This is a form of distributive shock caused by systemic vasodilation and increased capillary permeability in response to an overwhelming infection, rather than an initial failure of the cardiac pump.

A. Creatinine: 0.9 mg/dL (68.6 mcmol/L) B. Sodium: 146 mEq/L (150 mmol/L) C. Lactate: 7 mg/dL (.08 mmol/L) D. White blood cell count: 11,000/mm3 (11 x 109/L)

Correct Answer is C

Explanation

Choice A reason: A creatinine level of 0.9 mg/dL falls within the standard reference range for an adult, indicating preserved renal function and adequate glomerular filtration. While monitoring renal function is vital in shock due to the risk of acute kidney injury, this specific value does not require urgent notification.

Choice B reason: A sodium level of 146 mEq/L represents very mild hypernatremia or a high normal value, depending on the laboratory's specific reference range. While it warrants monitoring of the patient's fluid status and osmolality, it is not an acute indicator of systemic tissue hypoperfusion or imminent circulatory collapse.

Choice C reason: An elevated lactate level is a critical marker of anaerobic metabolism resulting from tissue hypoxia. In shock, inadequate oxygen delivery forces cells to switch from aerobic to anaerobic pathways. A lactate level of 7 mg/dL is significantly elevated, indicating severe systemic hypoperfusion and an increased risk of mortality.

Choice D reason: A white blood cell count of 11,000/mm3 is only slightly above the normal range and can be caused by various factors, including stress or minor inflammation. While it could suggest early infection, it is not as definitive or urgent an indicator of shock severity as lactate.

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A client suffered a 45 percent total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client is at the greatest risk of developing cardiogenic shock?

Correct Answer is A

Explanation

A nurse is caring for several clients at risk for shock. Which laboratory value is most important for the nurse to communicate with the primary health care provider?

Correct Answer is C

Explanation

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