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 A
Explanation
Choice A Reason: This choice is correct because slow, steady bubbling in the suction control chamber indicates that the suction is working properly and maintaining a negative pressure in the pleural space. The nurse should continue to monitor the client's respiratory status, such as breath sounds, oxygen saturation, and respiratory rate, to assess the effectiveness of the chest drainage system.
Choice B Reason: This choice is incorrect because checking the suction control outlet on the wall is not necessary unless there is no bubbling in the suction control chamber, which would indicate a problem with the suction source or setting. The nurse should ensure that the suction control outlet is set at the prescribed level, usually between 10 and 20 cm H2O.
Choice C Reason: This choice is incorrect because clamping the chest tube is not indicated unless there is a leak in the system or the chest drainage unit needs to be changed. Clamping the chest tube may cause a buildup of air or fluid in the pleural space, which can lead to tension pneumothorax or pleural effusion.
Choice D Reason: This choice is incorrect because checking the tubing connections for leaks is not necessary unless there is continuous bubbling in the water seal chamber, which would indicate an air leak in the system. The nurse should ensure that all tubing connections are tight and secure, and tape any loose connections.
Correct Answer is A
Explanation
Choice A Reason: This is correct because an osmotic diuretic, such as mannitol, works by creating an osmotic gradient that draws fluid from the brain tissue into the blood vessels, thereby reducing cerebral edema and intracranial pressure.
Choice B Reason: This is incorrect because an osmotic diuretic would decrease, not increase, the cell size in the brain by removing fluid from the intracellular space.
Choice C Reason: This is incorrect because an osmotic diuretic would decrease, not expand, the extracellular fluid volume by increasing the urine output and excreting excess fluid from the body.
Choice D Reason: This is incorrect because an osmotic diuretic would not provide fluid hydration, but rather cause fluid loss and dehydration.
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