A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply.

Hypovolemia

Difficulty breathing

Cardiovascular overload

Pulmonary edema

Hypoglycemia

Answer and Explanation

Correct Answer : B,C,D

Rationale:
A. Hypovolemia is incorrect in this context because the patient is receiving fluid replacement. While hypovolemia is the initial problem in many types of shock, the question focuses on complications of fluid therapy, not the underlying shock itself.

B. Difficulty breathing is correct because rapid or excessive fluid administration can lead to fluid overload, which increases pulmonary vascular pressure and can cause dyspnea.

C. Cardiovascular overload is correct because excessive fluid replacement can result in volume overload, leading to hypertension, tachycardia, jugular venous distention, and strain on the heart, particularly in patients with preexisting cardiac conditions.

D. Pulmonary edema is correct because fluid replacement complications can cause fluid accumulation in the alveoli, leading to impaired gas exchange, crackles on auscultation, hypoxia, and respiratory distress.

E. Hypoglycemia is incorrect because fluid replacement with crystalloids does not directly cause hypoglycemia. Hypoglycemia may occur in critically ill patients for other reasons, such as sepsis or insulin therapy, but it is not a typical complication of fluid resuscitation.

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Correct Answer is C

Explanation

Rationale:
A. Providing good perineal care is important for preventing skin breakdown and infection in clients with spinal cord injuries, but it does not address poikilothermia, which is the inability to regulate body temperature due to impaired autonomic function.

B. Inserting a gastric tube to decompress the stomach is used to manage gastric distention, nausea, or risk of aspiration, but it does not influence the client’s thermoregulation.

C. Keeping the client warm with extra blankets is the most appropriate intervention for poikilothermia. Poikilothermia occurs when the body cannot maintain a stable core temperature because of spinal cord injury that disrupts sympathetic nervous system pathways. Providing external warmth helps prevent hypothermia, reduces stress on the cardiovascular system, and supports overall homeostasis.

D. Stimulating the anal-rectal reflex is used to manage bowel function in spinal cord injury patients, but it does not address the thermoregulatory deficits associated with poikilothermia.

A. Increase afterload B. Decrease afterload C. Increase preload D. Decrease preload

Correct Answer is C

Explanation

Rationale:
A. Increasing afterload (the resistance the heart must pump against) is not the priority in this patient. In hypovolemic or cardiogenic shock due to trauma, increasing afterload could further strain cardiac output and worsen tissue perfusion.

B. Decreasing afterload is sometimes used in cases of heart failure to reduce cardiac workload, but in acute traumatic shock with hypotension, afterload reduction could further lower perfusion pressure and is not the primary goal.

C. The primary goal in a patient with hypotension and tachycardia following chest trauma is to increase preload (the volume of blood returning to the heart). Gunshot wounds to the chest can cause hemorrhagic shock, leading to decreased circulating blood volume. Restoring preload through rapid fluid resuscitation or blood products helps increase stroke volume and cardiac output, improving blood pressure, oxygen delivery, and perfusion of vital organs.

D. Decreasing preload would worsen hypotension and compromise organ perfusion. Reducing venous return in a patient already hypovolemic is contraindicated.

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A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care?

Correct Answer is C

Explanation

An adult patient presents to the ED with a gunshot wound to the chest. VS: BP 90/50; HR 120; RR 24; SpO2 86%. When anticipating treatment for this patient, the nurse recognizes the primary goal of treatment is to:

Correct Answer is C

Explanation

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