A client who has broken his femur presents to the emergency department with the following signs and symptoms: cool, moist skin, increased heart rate, and falling blood pressure. The nurse suspects the client is experiencing:

Low blood glucose

High blood glucose

Hemorrhage

Fluid volume excess

Answer and Explanation

The Correct Answer is C

Choice A reason: Low blood glucose (hypoglycemia) can cause cool, moist skin and tachycardia due to sympathetic activation, but falling blood pressure is less typical unless severe. Femur fractures are associated with significant blood loss, and the symptoms align more closely with hypovolemic shock from hemorrhage than metabolic disturbances like hypoglycemia.

Choice B reason: High blood glucose (hyperglycemia) may cause tachycardia and diaphoresis in severe cases (e.g., diabetic ketoacidosis), but cool, moist skin and falling blood pressure are not primary features. These symptoms are more indicative of hypovolemia from blood loss, as femur fractures can cause significant internal bleeding, making hyperglycemia unlikely.

Choice C reason: Hemorrhage from a femur fracture causes hypovolemic shock, characterized by cool, moist skin (due to vasoconstriction), increased heart rate (compensatory tachycardia), and falling blood pressure (due to volume loss). This is a life-threatening condition requiring urgent fluid resuscitation and hemorrhage control, aligning with the symptoms described and the injury’s severity.

Choice D reason: Fluid volume excess typically presents with edema, hypertension, and bounding pulses, not cool, moist skin or falling blood pressure. A femur fracture is unlikely to cause fluid overload acutely. The symptoms suggest hypovolemia from blood loss, not excess fluid, making this an incorrect diagnosis for the client’s presentation.

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Correct Answer is B

Explanation

Choice A reason: Pain medication is important for burn patients due to severe pain from exposed nerve endings. However, in the ABCDE approach, circulation (fluid status) takes precedence over pain management. A 30% burn causes significant fluid loss, risking hypovolemic shock, making IV fluids the priority to stabilize the patient before addressing pain.

Choice B reason: A 30% burn injury to the lower extremities causes significant plasma leakage, leading to hypovolemia and potential shock. Administering IV fluids, typically via the Parkland formula, restores intravascular volume, maintains blood pressure, and ensures organ perfusion. In the ABCDE approach, circulation is prioritized, making fluid resuscitation the first intervention.

Choice C reason: Cleaning and dressing burn wounds prevent infection, a major complication due to loss of the skin barrier. However, this is not the immediate priority in the acute phase. Fluid resuscitation addresses life-threatening hypovolemia first, as per the ABCDE approach, ensuring circulatory stability before wound care is initiated.

Choice D reason: A tetanus booster prevents infection from Clostridium tetani, especially in contaminated burns. While important, it is not the first priority in the acute management of a 30% burn. Fluid resuscitation addresses immediate life-threatening hypovolemia, which takes precedence over prophylactic measures like tetanus vaccination in the ABCDE framework.

A. Hypervolemia B. Hypovolemia C. Hyperkalemia D. Hyponatremia

Correct Answer is A

Explanation

Choice A reason: In end-stage kidney disease, the kidneys cannot excrete excess fluid, leading to hypervolemia. This causes fluid overload, manifesting as shortness of breath (from pulmonary edema), lower extremity swelling, crackles in the lungs, and elevated blood pressure due to increased intravascular volume. These symptoms align with fluid retention, a common ESKD complication.

Choice B reason: Hypovolemia involves reduced fluid volume, causing symptoms like hypotension, tachycardia, and dry mucous membranes. The client’s symptoms of swelling, crackles, and elevated blood pressure indicate fluid overload, not deficit. In ESKD, the kidneys’ inability to excrete fluid makes hypervolemia, not hypovolemia, the likely cause of these findings.

Choice C reason: Hyperkalemia, common in ESKD due to reduced potassium excretion, causes cardiac arrhythmias, muscle weakness, or ECG changes. It does not directly cause shortness of breath, swelling, crackles, or hypertension. These symptoms point to fluid overload rather than electrolyte imbalance, making hyperkalemia an incorrect diagnosis for this presentation.

Choice D reason: Hyponatremia, low sodium levels, may cause neurological symptoms like confusion or seizures in ESKD but is not associated with shortness of breath, swelling, crackles, or hypertension. These symptoms reflect fluid overload from impaired renal excretion, making hypervolemia the correct diagnosis, as hyponatremia does not explain the clinical findings.

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A client who has broken his femur presents to the emergency department with the following signs and symptoms: cool, moist skin, increased heart rate, and falling blood pressure. The nurse suspects the client is experiencing:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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