A client with G.I. bleeding has been in the Emergency Department for hours and has vomited bright red blood three times in the past 30 minutes. You report this to the charge nurse who tells you not to worry because the blood pressure has not dropped. You know that
fluid shifts will maintain the client's blood volume.
decreased blood volume will be demonstrated by a decreased blood pressure.
vasoconstriction is a compensatory mechanism which may initially keep blood pressure stable despite blood loss.
monitoring blood pressure is not an important activity in the early stages of the shock state.
The Correct Answer is C
A. Fluid shifts will maintain the client's blood volume: Although fluid shifts from the interstitial to the intravascular space can partially compensate for blood loss, this process is not immediate or sufficient to fully maintain circulating volume during acute hemorrhage. Relying on this mechanism alone could delay recognition of hypovolemic shock.
B. Decreased blood volume will be demonstrated by a decreased blood pressure: Early in hemorrhage, blood pressure may remain normal due to compensatory mechanisms such as increased heart rate and vasoconstriction. Hypotension often occurs only after significant blood loss, so relying solely on blood pressure may underestimate severity.
C. Vasoconstriction is a compensatory mechanism which may initially keep blood pressure stable despite blood loss: The sympathetic nervous system responds to acute blood loss by constricting peripheral vessels, maintaining perfusion to vital organs and temporarily stabilizing blood pressure. A client can therefore continue to have stable blood pressure even with ongoing significant hemorrhage.
D. Monitoring blood pressure is not an important activity in the early stages of the shock state: Continuous monitoring of blood pressure remains essential, even in early hemorrhage, because trends can indicate decompensation. Ignoring blood pressure measurements could delay timely interventions and compromise patient safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Check the client's hemoglobin and hematocrit levels: Hemoglobin and hematocrit provide information about oxygen-carrying capacity and blood loss but do not reflect fluid overload. Changes in these values occur more slowly and are not reliable for detecting acute volume excess during transfusion.
B. Auscultate for irregular cardiac rhythm: An irregular rhythm may indicate arrhythmias, which can occur with electrolyte imbalances or underlying cardiac disease, but it is not the primary indicator of fluid overload. Rhythm changes alone do not reliably signal pulmonary congestion.
C. Auscultate for rales and rhonchi, and observe for shortness of breath: Crackles (rales) and rhonchi on lung auscultation, along with dyspnea, are key indicators of pulmonary fluid accumulation. These findings signal early fluid overload, making this assessment the most direct and effective way to detect this complication during transfusion.
D. Assess for chills, fever, flushing and muscle aches: These signs are characteristic of a febrile or hemolytic transfusion reaction, not fluid overload. While important to monitor for, they do not reflect pulmonary congestion or hypervolemia, which require different assessment parameters.
Correct Answer is B
Explanation
A. distended neck veins, widening pulse pressure, drop in cardiac output: Cardiac tamponade typically causes narrowing, not widening, of the pulse pressure due to equalization of diastolic pressures and reduced stroke volume.
B. drop in cardiac output, narrowing pulse pressure, jugular vein distension: These are classic signs of cardiac tamponade. Accumulation of fluid in the pericardial sac restricts ventricular filling, decreasing stroke volume and cardiac output, narrowing pulse pressure, and causing venous congestion visible as jugular vein distension.
C. bradycardia, hypotension, narrowing pulse pressure: Hypotension and narrowed pulse pressure are relevant, but bradycardia is not a typical early sign; tachycardia is more common as a compensatory response to reduced cardiac output.
D. hypotension, diminished breath sounds, jugular vein distention: Hypotension and jugular vein distension occur, but diminished breath sounds are more associated with pleural effusion or pneumothorax, not cardiac tamponade.
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