A nurse is 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?

Unconsciousness

Tachycardia

Cold clammy skin

Diminished urine output

Answer and Explanation

The Correct Answer is B

Choice A reason: Unconsciousness is not typically a finding in the early compensatory stage of hypovolemic shock; it may occur in more advanced stages.

Choice B reason: Tachycardia, or rapid heartbeat, is a compensatory mechanism to maintain cardiac output during the early stages of hypovolemic shock.

Choice C reason: Cold clammy skin is a result of peripheral vasoconstriction, which is a compensatory response to maintain blood flow to vital organs.

Choice D reason: Diminished urine output occurs as the body conserves fluid in response to decreased blood volume.

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Correct Answer is C

Explanation

Choice A reason: Using the incentive spirometer is important, but it is not specifically related to deep breathing and coughing exercises.

Choice B reason: Breathing deeply and coughing every 4 hours is part of postoperative care, but it does not indicate understanding of the technique to protect the incision.

Choice C reason: Splinting the incision with a pillow while coughing is a recommended technique to support the incision and reduce pain during coughing, indicating an understanding of the instructions.

Choice D reason: Lying flat is not recommended for deep breathing and coughing exercises as it can inhibit lung expansion and is not conducive to effective coughing.

A. Call the surgeon to talk to the patient. B. Offer to call the chaplain for this patient. C. Inform the patient that the survival rate for this surgery is very high. D. Recommend analgesics only during surgery.

Correct Answer is C

Explanation

Choice A reason: Direct communication with the surgeon can provide the patient with reassurance and specific information about the surgery, which may alleviate fears.

Choice B reason: Offering spiritual support may be helpful, but it does not directly address the patient's concern about the surgery itself.

Choice C reason: Providing statistics may be reassuring, but it may not fully address the patient's individual fears.

Choice D reason: Recommending analgesics only addresses pain management and not the patient's expressed fear regarding the surgery.

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A nurse is 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?

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