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 B
Explanation
TPN is a form of intravenous nutrition that provides glucose, amino acids, lipids, vitamins, minerals, and electrolytes to clients who cannot eat or absorb nutrients through their gastrointestinal tract. Discontinuing TPN abruptly can cause a sudden drop in blood glucose levels, leading to hypoglycemia .
Hyperglycemia can occur during TPN administration if the glucose infusion rate is too high or if the client has insulin resistance . Diarrhea can occur as a result of infection, bowel ischemia, or intolerance to enteral feeding . Hypertension can occur due to fluid overload, electrolyte imbalance, or vascular complications .
Correct Answer is D
Explanation
The client has hypokalemia, which is a low level of potassium in the blood. Hypokalemia can cause cardiac arrhythmias, which can be life-threatening. The nurse should initiate cardiac monitoring first to assess the client's heart rhythm and rate, and intervene if any abnormalities are detected. Administering an IV potassium drip is an appropriate intervention for hypokalemia, but it is not the first priority. Listening to the client's bowel sounds and checking the client's hand grasps are also relevant assessments for hypokalemia, as it can cause decreased bowel motility and muscle weakness, but they are not as urgent as cardiac monitoring.
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