A nurse is assessing a client with suspected hypovolemic shock. Which finding is the earliest indicator of this condition?

Hypotension

Tachycardia

Cool, clammy skin

Decreased urine output

Answer and Explanation

The Correct Answer is B

Choice A reason: Hypotension occurs in hypovolemic shock when blood volume loss exceeds 15–30%, indicating a later stage. Compensatory mechanisms like vasoconstriction maintain blood pressure initially. Tachycardia precedes hypotension as the body responds to reduced volume, making it a less early sign than increased heart rate.

Choice B reason: Tachycardia is the earliest sign of hypovolemic shock, occurring with 5–15% blood volume loss. The sympathetic nervous system increases heart rate to compensate for reduced cardiac output, maintaining perfusion. This precedes other signs like hypotension or oliguria, making it the first detectable indicator in shock assessment.

Choice C reason: Cool, clammy skin results from vasoconstriction in hypovolemic shock, a compensatory response to maintain blood pressure. This occurs after tachycardia, as the body prioritizes increasing heart rate to compensate for volume loss. Skin changes are a later sign compared to the initial cardiovascular response of tachycardia.

Choice D reason: Decreased urine output (oliguria) occurs in hypovolemic shock when renal perfusion decreases, typically after significant volume loss. This is a later sign, as the kidneys receive reduced blood flow after compensatory mechanisms like tachycardia fail. Tachycardia appears earlier, as it is the body’s initial response to volume loss.

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Correct Answer is B

Explanation

Choice A reason: pH 7.48, PaCO2 40 mmHg, HCO3- 24 mEq/L indicates alkalosis, not acidosis. Diabetic ketoacidosis (DKA) causes metabolic acidosis due to ketone accumulation, lowering pH and bicarbonate. Normal PaCO2 and HCO3- rule out DKA, as compensatory hyperventilation would lower PaCO2 in response to acidosis.

Choice B reason: pH 7.30, PaCO2 30 mmHg, HCO3- 18 mEq/L indicates metabolic acidosis with respiratory compensation. In DKA, ketone production lowers pH and bicarbonate, while hyperventilation reduces PaCO2 to compensate. These values align with DKA’s acid-base imbalance, reflecting the body’s attempt to correct acidosis through increased respiration.

Choice C reason: pH 7.50, PaCO2 45 mmHg, HCO3- 30 mEq/L indicates metabolic alkalosis, not acidosis. DKA causes acidosis from ketone accumulation, not alkalosis. Elevated bicarbonate and normal PaCO2 suggest a different condition, like vomiting-induced alkalosis, making this inconsistent with the metabolic acidosis seen in DKA.

Choice D reason: pH 7.35, PaCO2 38 mmHg, HCO3- 22 mEq/L indicates normal acid-base balance. DKA results in metabolic acidosis with low pH and bicarbonate due to ketone production. Normal values do not reflect the acidotic state of DKA, where compensatory mechanisms would alter PaCO2 and HCO3- significantly.

A. Rebound tenderness at McBurney’s point B. Left lower quadrant pain C. High-pitched bowel sounds D. Soft, non-tender abdomen

Correct Answer is A

Explanation

Choice A reason: Rebound tenderness at McBurney’s point (right lower quadrant) indicates peritoneal irritation, a hallmark of appendicitis. The inflamed appendix causes localized pain, exacerbated by pressure release due to peritoneal inflammation. This specific finding is highly suggestive of appendicitis, distinguishing it from other abdominal conditions.

Choice B reason: Left lower quadrant pain is not typical for appendicitis, which usually presents in the right lower quadrant due to the appendix’s anatomical location. Left-sided pain may suggest conditions like diverticulitis or colitis, but it does not align with the localized inflammation characteristic of appendicitis.

Choice C reason: High-pitched bowel sounds suggest increased peristalsis, as in early obstruction, but are not specific to appendicitis. Appendicitis may reduce bowel sounds due to peritoneal irritation. Rebound tenderness is a more direct indicator, as it reflects the localized inflammation and irritation of appendicitis.

Choice D reason: A soft, non-tender abdomen is inconsistent with appendicitis, which causes localized pain and tenderness due to inflammation. A non-tender abdomen suggests a normal or alternative condition, not appendicitis, where peritoneal irritation typically produces tenderness, especially at McBurney’s point, upon palpation or rebound.

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A nurse is assessing a client with suspected hypovolemic shock. Which finding is the earliest indicator of this condition?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with diabetic ketoacidosis. Which arterial blood gas result is most consistent with this condition?

Correct Answer is B

Explanation

A nurse is evaluating a client with suspected appendicitis. Which physical assessment finding is most indicative of this condition?

Correct Answer is A

Explanation

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