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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because the most common cause of infusion pump alarms is occlusion or obstruction of the IV line, which can be due to kinking, bending, or compression of the tubing or catheter by the client's arm or body position. By repositioning the client's arm, the nurse can relieve the occlusion and restore the flow of the IV fluid.
This action should be done before checking for other possible causes of alarm, such as redness at the IV site (which could indicate infection or inflammation), loose tubing connections (which could cause leakage or air embolism), or clogged IV catheter (which could require flushing with saline or heparin solution).
Correct Answer is C
Explanation
A serum sodium level of 120 mEq/L indicates hyponatremia, which is a condition where there is an excess of water relative to sodium in the body fluids. Hyponatremia can cause various neurological symptoms such as confusion, lethargy, seizures, coma, and death.
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