A nurse is attending to a client experiencing hypovolemic shock.

What findings should the nurse anticipate?

Hypertension

Purpura

Bradypnea

Oliguria

Answer and Explanation

The Correct Answer is D

Choice A rationale
Hypertension is not typically associated with hypovolemic shock. In fact, hypotension, or low blood pressure, is more common.
Choice B rationale
Purpura, or blood spots, are not typically associated with hypovolemic shock.
Choice C rationale
Bradypnea, or slow breathing, is not typically associated with hypovolemic shock. Rapid, shallow breathing is more common.
Choice D rationale
Oliguria, or decreased urine output, is a common finding in hypovolemic shock. It occurs due to decreased blood flow to the kidneys.

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Correct Answer is B

Explanation

Choice A rationale
The vital signs presented in this choice are within the normal range. A blood pressure of 118/76 mm Hg is considered normal. A heart rate of 92/min is slightly elevated but still within the normal range (60-100 beats per minute). A temperature of 38.1° C (100.6° F) indicates a slight fever, which could be a response to an infection or inflammation. An oxygen saturation of 95% on room air is within the normal range (95%-100%).
Choice B rationale
The vital signs presented in this choice indicate that the patient may be experiencing a respiratory issue. A blood pressure of 126/84 mm Hg is slightly elevated but still within the acceptable range. A heart rate of 104/min is high, indicating that the heart is working harder than normal. A respiratory rate of 24/min is also high, suggesting that the patient may be having difficulty breathing. A temperature of 38.5 C (101.3* F) indicates a fever, which could be a response to an infection. An oxygen saturation of 92% on room air is below the normal range (95%-100%), suggesting that the patient is not getting enough oxygen. This is the vital sign that should be addressed first.

A. Reports pain at burn site B. Hands are edematous C. Burned area has a foul odor D. Temperature is 99.8 degrees Fahrenheit .

Correct Answer is C

Explanation

Choice A rationale
While pain at the burn site can be a symptom of many conditions, it is not a specific indicator of a local infection in the burned area.
Choice B rationale
Edematous hands can be a sign of many conditions, including burns, but they are not a specific indicator of a local infection in the burned area.
Choice C rationale
A foul odor from the burned area is a strong indicator of a local infection. Bacteria and other microorganisms that cause infections can produce waste products that have a foul smell.
Choice D rationale
A temperature of 99.8 degrees Fahrenheit is within the normal body temperature range and is not a specific indicator of a local infection in the burned area.

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A nurse is attending to a client experiencing hypovolemic shock. What findings should the nurse anticipate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Given the following vital signs, which should the nurse address first in the patient?

Correct Answer is B

Explanation

When caring for a patient with burns, which assessment data will alert the nurse to the possibility of a local infection of the burned area?

Correct Answer is C

Explanation

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A nurse is attending to a client experiencing hypovolemic shock.

What findings should the nurse anticipate?