A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

Urine output 45 mL/hr

Potassium 5.2 mEq/L

Capillary refill 1.5 seconds

PaCO2 37 mm Hg

Answer and Explanation

The Correct Answer is B

This indicates hyperkalemia, which is a common complication of severe burn injuries due to massive cell destruction and fluid loss from damaged tissues. Hyperkalemia can lead to cardiac dysrhythmias and arrest, which are signs of hypovolemic shock.

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Correct Answer is D

Explanation

Thrombocytopenia is a condition where the blood has a low platelet count, which can impair blood clotting and increase the risk of bleeding. Heparin is an anticoagulant that prevents blood clots from forming or growing, but it can also cause or worsen thrombocytopenia and bleeding.

Therefore, heparin is contraindicated for clients who have thrombocytopenia or are at risk of developing it. The other conditions are not contraindications to receiving heparin.

A. "I will empty my bag when it is full." B. "I will take a laxative when I'm constipated." C. "I will expect my stools to be loose." D. "I will eat a high-fiber diet."

Correct Answer is C

Explanation

An ileostomy is a surgical opening in the abdomen that connects the end of the small intestine (ileum) to a pouch or bag on the outside of the body. The ileostomy bypasses the large intestine (colon) and rectum, which normally absorb water and form solid stools. Therefore, the client should expect their stools to be loose and watery. The client should empty their bag several times a day, not when it is full, to prevent leakage and skin irritation. The client should avoid laxatives, which can cause dehydration and electrolyte imbalance. The client should also avoid high-fiber foods, which can cause blockage or irritation of the ileostomy.

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A nurse is caring for a client who has a severe burn injury. The nurse should recognize which of the following client findings as an indication of hypovolemic shock?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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