A nurse is assessing a client with suspected hypovolemic shock following trauma. Which clinical finding is most indicative of this condition?

Blood pressure of 110/70 mm Hg

Heart rate of 120 beats/min

Warm, dry skin

Urine output of 40 mL/hr

Answer and Explanation

The Correct Answer is B

Choice A reason: Blood pressure of 110/70 mm Hg is within normal range and does not indicate hypovolemic shock, which typically presents with hypotension (e.g., <90/60 mm Hg). Early shock may have normal blood pressure, but tachycardia (heart rate 120 beats/min) is a more sensitive indicator of compensatory response to volume loss.

Choice B reason: Heart rate of 120 beats/min indicates tachycardia, a hallmark of hypovolemic shock. In trauma, blood loss reduces circulating volume, triggering sympathetic activation to increase heart rate, compensating for decreased cardiac output. This is the most indicative finding, as it appears early and reflects the body’s response to hypovolemia.

Choice C reason: Warm, dry skin is not typical of hypovolemic shock, which causes cool, clammy skin due to vasoconstriction from sympathetic activation. Warm skin may occur in distributive shock (e.g., sepsis). Tachycardia is a more specific indicator of hypovolemia, making this finding incorrect for the suspected condition.

Choice D reason: Urine output of 40 mL/hr is within normal range (30-50 mL/hr) and does not indicate hypovolemic shock, which typically reduces output (<30 mL/hr) due to decreased renal perfusion. Tachycardia (120 beats/min) is a more immediate and sensitive sign of hypovolemia, making urine output less indicative in early shock.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Evaluating chest expansion assesses breathing, the second priority in the ABCDE approach. Trauma from a motor vehicle crash may cause rib fractures, pneumothorax, or hemothorax, impairing ventilation. Unequal or absent expansion indicates a life-threatening issue, requiring immediate intervention like chest tube placement to restore adequate respiration.

Choice B reason: Assessing capillary refill evaluates peripheral perfusion, a circulation parameter in the ABCDE approach. While important, it is secondary to airway and breathing. Trauma patients may have shock, but chest injuries affecting ventilation (e.g., pneumothorax) are more immediate threats, making chest expansion the first assessment to ensure respiratory function.

Choice C reason: Checking pupillary response assesses neurological status (disability in ABCDE), relevant for head trauma. However, breathing takes precedence over neurological assessment in trauma patients. Chest injuries can cause rapid respiratory failure, making chest expansion evaluation critical to identify life-threatening conditions like flail chest or pneumothorax before neurological checks.

Choice D reason: Checking orientation to place and time assesses neurological function, part of the disability component in ABCDE. While important in trauma, it is secondary to airway and breathing. Chest injuries from a crash can compromise ventilation, making chest expansion the priority to detect and address immediate respiratory threats before neurological evaluation.

A. A female who is pregnant at 20 weeks of gestation, has multiple cuts and abrasions, and is walking around B. A client who has a simple fracture of the femur, multiple scratches on both legs, and is crying hysterically C. A client who has severe head injuries, respiratory rate 8/min, and is unresponsive D. A client who has a piece of wood punctured into the chest wall and has an audible hissing sound coming from the wound

Correct Answer is D

Explanation

Choice A reason: A pregnant female with cuts and abrasions who is ambulatory has stable vital signs in the triage context. Minor injuries like cuts do not compromise airway, breathing, or circulation immediately. In mass casualty triage, she is a lower priority (green tag) compared to clients with life-threatening conditions like chest trauma.

Choice B reason: A simple femur fracture with scratches and emotional distress indicates pain and potential blood loss but not immediate life-threatening issues. Crying hysterically suggests intact neurological and airway status. In triage, this client is stable (yellow tag) compared to those with airway or breathing compromise, making them a lower priority.

Choice C reason: Severe head injuries with a respiratory rate of 8/min and unresponsiveness indicate neurological and respiratory compromise. This is critical, warranting a red tag, but the client with a chest wound and hissing sound suggests a tension pneumothorax, which can cause immediate cardiopulmonary collapse, taking precedence in triage due to rapid lethality.

Choice D reason: A chest wound with an audible hissing sound indicates a sucking chest wound or tension pneumothorax, a life-threatening emergency. Air entering the pleural space collapses the lung, impairing breathing and circulation. In mass casualty triage, this client requires immediate intervention (red tag) to seal the wound and restore respiratory function, making them the priority.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is assessing a client with suspected hypovolemic shock following trauma. Which clinical finding is most indicative of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse in a trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Correct Answer is A

Explanation

A nurse is helping to triage a group of clients at a mass casualty incident who were involved in an explosion at a local factory. Which of the following clients should the nurse tag to be the priority for care?

Correct Answer is D

Explanation

This is an extra credit question: A nurse is caring for a client receiving hemodialysis. Exhibits A nurse is for a client who has received hemodialysis. Which of the following assessment findings require follow-up?

A nurse is caring for a client who is undergoing peritoneal dialysis. Which of the following should the nurse report immediately to the provider?

A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Which of the following is a clinical symptom most commonly associated with Acute Respiratory Distress Syndrome (ARDS)?

Which clinical finding is most indicative of hypoxemic respiratory failure?

A client is unable to take a deep breath and does not want to get out of bed due to chest tube discomfort. To increase the client's compliance with ambulation and deep breathing, the nurse should: