A nurse is caring for a client who returns to the intensive care unit after a mass resection from the gastrointestinal tract. The client experienced bleeding throughout the procedure. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Increase in the heart rate from 90 to 120/min.

Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).

Decrease in the urinary output from 120 mL to 115 mL per hour.

Decrease in the respiratory rate from 24 to 16/min.

Answer and Explanation

The Correct Answer is A

A. Tachycardia is an early compensatory sign of hypovolemic shock due to decreased circulating volume.
B. Increased temperature suggests infection or inflammation, not hypovolemic shock.
C. A slight decrease in urine output from 120 to 115 mL/hr is not significant; oliguria would be a more concerning sign.
D. A decrease in respiratory rate is not typical of hypovolemic shock, which usually causes tachypnea.

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Correct Answer is C

Explanation

A. Hypocalcemia is not a primary concern in DKA treatment.
B. Hyponatremia can occur but is less immediately critical than potassium imbalance.
C. During treatment of DKA, insulin administration drives potassium into cells, potentially causing dangerous hypokalemia, so close monitoring of potassium levels is essential.
D. Hypomagnesemia is less common and not the primary focus during DKA management.

Correct Answer is ["225"]

Explanation

4 mL × body weight (kg) × % total body surface area (TBSA) burned = total fluid requirement in the first 24 hours

Half of this volume is given in the first 8 hours post-burn (from the time of injury).

The remaining half is given over the next 16 hours.

Step 1: Convert weight from pounds to kilograms
220 lbs ÷ 2.2 = 100 kg

Step 2: Determine % TBSA burned
anterior trunk burns, which corresponds to 18% TBSA (anterior trunk is about 18%).

Step 3: Calculate total fluid volume for 24 hours
4 mL × 100 kg × 18 = 7200 mL total in 24 hours

Step 4: Calculate remaining fluid to give over the next 16 hours
Half (first 8 hours) = 7200 ÷ 2 = 3600 mL (already given)
Remaining 16 hours = 3600 mL

Step 5: Calculate the hourly rate
3600 mL ÷ 16 hours = 225 mL/hour

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A nurse is caring for a client who returns to the intensive care unit after a mass resection from the gastrointestinal tract. The client experienced bleeding throughout the procedure. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

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Naxlex Comprehensive Predictor Exams

A nurse caring for a client with diabetic ketoacidosis (DKA) has initiated the treatment plan. Which of the following electrolyte imbalance will the nurse be monitoring closely for this client?

Correct Answer is C

Explanation

Correct Answer is ["225"]

Explanation

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