A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Hypertension
Bradypnea
Oliguria
Flushing of the skin
The Correct Answer is C
Choice A Reason: This is incorrect because hypertension is a condition of high blood pressure. A client who has hypovolemic shock is more likely to have hypotension, which is a condition of low blood pressure, due to fluid loss and reduced cardiac output.
Choice B Reason: This is incorrect because bradypnea is a condition of slow breathing. A client who has hypovolemic shock is more likely to have tachypnea, which is a condition of fast breathing, due to hypoxia and increased respiratory demand.
Choice C Reason: This is correct because oliguria is a condition of low urine output. A client who has hypovolemic shock may have oliguria due to decreased renal perfusion and activation of the renin-angiotensin-aldosterone system, which causes sodium and water retention.
Choice D reason: This is incorrect because flushing of the skin is a condition of redness and warmth of the skin. A client who has hypovolemic shock may have pallor and coolness of the skin due to vasoconstriction and reduced blood flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.
Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreflexia or relieve the symptoms.
Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreflexia.
Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.
Correct Answer is B
Explanation
Choice A Reason: Preventing musculoskeletal disability is important, but not the priority focus of care. The nurse should first assess and manage the client's life-threatening injuries, such as airway obstruction, bleeding, shock, or brain injury.
Choice B Reason: Airway protection is the priority focus of care for a client with multiple system trauma. The nurse should ensure that the client has a patent airway and adequate ventilation, as any compromise in these areas can quickly lead to hypoxia, respiratory failure, and death.
Choice C Reason: Stabilizing cardiac arrhythmias is also important, but not the priority focus of care. The nurse should monitor the client's cardiac rhythm and treat any arrhythmias that may occur, but only after securing the airway and breathing.
Choice D Reason: Decreasing intracranial pressure is another important goal, but not the priority focus of care. The nurse should assess the client's neurological status and intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. However, these measures are secondary to ensuring adequate oxygenation and perfusion.
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