A nurse assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock.
Which of the following findings should the nurse expect?

Tachycardia.

Diminished urine output.

Cold clammy skin.

Unconsciousness.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Tachycardia, or a rapid heart rate, is a common early sign of hypovolemic shock as the body tries to compensate for the decreased blood volume by increasing the heart rate.

Choice B rationale:

Diminished urine output is a sign of hypovolemic shock, but it is not typically an early sign.

Choice C rationale:

Cold, clammy skin is a sign of hypovolemic shock, but it is not typically an early sign.

Choice D rationale:

Unconsciousness is a late sign of hypovolemic shock, indicating severe blood loss and inadequate perfusion to the brain.

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Correct Answer is A

Explanation

Choice A rationale:

A client who is short of breath is experiencing a life-threatening situation and should be seen first.

Choice B rationale:

A client who received pain medication 30 min ago is likely to be comfortable and can be seen later.

Choice C rationale:

A client who is to be discharged at 11:00 can be seen closer to the discharge time.

Choice D rationale:

A client who is ambulatory and going for an x-ray at 10:00 can be seen after the x-ray.

A. Ask the client's full name and date of birth. B. Verify the client's room number. C. Ask a family member to verify the client's identity. D. Check the client's name on the medication administration record (MAR)

Correct Answer is A

Explanation

Choice A rationale:

Asking the client’s full name and date of birth is the most reliable method of identification.

Choice B rationale:

Verifying the client’s room number is not reliable because room assignments can change.

Choice C rationale:

Asking a family member to verify the client’s identity is not always possible or reliable.

Choice D rationale:

Checking the client’s name on the medication administration record (MAR) is important but should be done in conjunction with direct client identification.

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A nurse assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock.Which of the following findings should the nurse expect?

Nursing Test Bank

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A nurse assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock.
Which of the following findings should the nurse expect?