Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Urine output 45 mL/hr
B. Potassium 5.2 mEq/L
This indicates hyperkalemia, which is a common complication of severe burn injuries due to massive cell destruction and fluid lossfrom damaged tissues. Hyperkalemia can lead to cardiac dysrhythmias and arrest, which are signs of hypovolemic shock.
C. Capillary refill 1.5 seconds
D. PaCO2 37 mm Hg
This question is an excerpt from Nurse Dive's nursing test bank - ATI RN adult medical surgical 2019 with NGN - Proctored Exam 3. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is providing discharge teaching to a client who has an impaired immune system due to chemotherapy. Which of the following information should the nurse include in the teaching?
A. "Change the water in your drinking glass every 4 hours."
B. "Change your pet's litter box daily."
C. "Wash your toothbrush in the dishwasher once each month."
D. "Wash your perineal area two times each day with antimicrobial soap."
The client should wash their perineal area twice a day with antimicrobial soap to prevent infection and irritation. This is especially important for clients who have an impaired immune system due to chemotherapy, as they are more susceptible to infections and complications.
Full Explanation
The client should wash their perineal area twice a day with antimicrobial soap to prevent infection and irritation. This is especially important for clients who have an impaired immune system due to chemotherapy, as they are more susceptible to infections and complications.
A nurse is reviewing the medical record of a client who is to undergo open heart surgery.
Which of the following findings should the nurse report to the provider as a contraindication to receiving heparin?
A. COPD
B. rheumatoid arthritis
C. Thalassemia
D. Thrombocytopenia
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.
Full 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 nurse in a provider's office is caring for a client who has total vision loss and is the handler of a service dog. Which of the following actions should the nurse take to show consideration for the client and the service animal?
A. Command the dog to sit while talking with the client.
B. Consult the client before approaching the dog.
The nurse should consult the client before approaching the dog, as the service animal is working and may have specific instructions from the handler on how to interact with others. The nurse should respect the client's autonomy and preferences regarding their service animal and not interfere with their bond or function.
C. Offer the dog a bowl of water to demonstrate caring.
D. Pet the dog briefly to demonstrate acceptance.
Full Explanation
The nurse should consult the client before approaching the dog, as the service animal is working and may have specific instructions from the handler on how to interact with others. The nurse should respect the client's autonomy and preferences regarding their service animal and not interfere with their bond or function.