A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Hypertension

Bradypnea

Oliguria

Flushing of the skin

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because hypertension is a condition of high blood pressure. A client who has hypovolemic shock is more likely to have hypotension, which is a condition of low blood pressure, due to ﬂuid loss and reduced cardiac output.

Choice B Reason: This is incorrect because bradypnea is a condition of slow breathing. A client who has hypovolemic shock is more likely to have tachypnea, which is a condition of fast breathing, due to hypoxia and increased respiratory demand.

Choice C Reason: This is correct because oliguria is a condition of low urine output. A client who has hypovolemic shock may have oliguria due to decreased renal perfusion and activation of the renin-angiotensin-aldosterone system, which causes sodium and water retention.

Choice D reason: This is incorrect because ﬂushing of the skin is a condition of redness and warmth of the skin. A client who has hypovolemic shock may have pallor and coolness of the skin due to vasoconstriction and reduced blood ﬂow.

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Correct Answer is ["A","C","E"]

Explanation

Choice A Reason: This choice is correct because verifying the prescribed ventilator settings daily is an important intervention to ensure that the client is receiving adequate ventilation and oxygenation. The ventilator settings include parameters such as tidal volume, respiratory rate, fraction of inspired oxygen (FiO2), positive end-expiratory pressure (PEEP), and peak inspiratory pressure (PIP). The nurse should check that the settings match the prescription and report any changes or alarms to the provider.

Choice B Reason: This choice is incorrect because applying restraints if the client becomes agitated is not a recommended intervention to prevent complications. Restraints may cause injury, infection, or psychological distress to the client and increase the risk of ventilator-associated pneumonia (VAP). The nurse should use alternative methods to manage agitation, such as sedation, analgesia, or environmental modification.

Choice C Reason: This choice is correct because administering pantoprazole as prescribed is an important intervention to prevent complications. Pantoprazole is a proton pump inhibitor (PPI) that reduces the production of stomach acid and prevents gastroesophageal reﬂux disease (GERD) and stress ulcers. These conditions can cause aspiration, bleeding, or infection in clients who are receiving mechanical ventilation.

Choice D Reason: This choice is incorrect because repositioning the endotracheal tube to the opposite side of the mouth daily is not a recommended intervention to prevent complications. Repositioning the endotracheal tube may cause trauma, bleeding, or displacement of the tube, which can compromise the airway and ventilation of the client. The nurse should secure the tube with tape or a device and check its position regularly using chest x-ray or end-tidal CO2 monitoring.

Choice E Reason: This choice is correct because elevating the head of the bed to at least 30° is an important intervention to prevent complications. Elevatin the head of the bed helps to reduce the risk of aspiration, which is the inhalation of gastric contents or secretions into the lungs. Aspiration can cause pneumonia, atelectasis, or respiratory failure in clients who are receiving mechanical ventilation.

A. 54 percent B. 36 percent C. 18 percent D. 9 percent

Correct Answer is A

Explanation

Choice A Reason: To calculate the total body surface area (TBSA) affected by burns using the Rule of Nines, the body is divided into sections, each representing a percentage of TBSA:

Front of one leg = 9%
Back of one leg = 9%
Front of one arm = 4.5%
Back of one arm = 4.5%

Now for the calculation:

Both legs (front and back):
- Front of both legs = 9% × 2 = 18%
- Back of both legs = 9% × 2 = 18%
- Total for both legs = 18% + 18% = 36%
Both arms (front and back):
- Front of both arms = 4.5% × 2 = 9%
- Back of both arms = 4.5% × 2 = 9%
- Total for both arms = 9% + 9% = 18%
Total TBSA:
- Legs (36%) + Arms (18%) = 54%

The nurse should document burns to 54% of the client's total body surface area (TBSA).

Choice B Reason:This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.

Choice C Reason: This choice is incorrect because it uses the original rule of nines for adults, not children. It also does not account for the depth and degree of the burns.

Choice D Reason: This choice is incorrect because it uses a random percentage that does not correspond to any rule or calculation.

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A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

A nurse in an emergency department is caring for an adult client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is A

Explanation

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