A nurse is caring for a client who is at risk for developing shock. Which of the following findings is the earliest indicator that this complication is occurring?

Increased respiratory rate

Hypotension

Anuria

Decreased level of consciousness

Answer and Explanation

The Correct Answer is A

A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.

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Correct Answer is A

Explanation

A. This is the correct sequence of normal electrical conduction through the heart: the impulse originates in the sinoatrial (SA) node, travels to the atrioventricular (AV) node, then to the bundle of His, down the right and left bundle branches, and finally through the Purkinje fibers.
B. This choice places the Purkinje fibers before the bundle branches, which is incorrect.
C. The AV node does not initiate conduction; the SA node is the natural pacemaker of the heart.
D. This sequence incorrectly places the bundle branches before the bundle of His.

A. Sepsis B. Otitis media C. Deep vein thrombosis D. Bacterial endocarditis

Correct Answer is D

Explanation

A. Sepsis is a general systemic infection that can arise from many sources but is not the specific concern addressed by prophylactic antibiotics in valve replacement patients.
B. Otitis media (middle ear infection) is unrelated to dental or surgical procedures and not a concern in valve replacement clients.
C. Deep vein thrombosis (DVT) is prevented with anticoagulants and mobility, not antibiotics.
D. Bacterial endocarditis is a serious infection of the heart's inner lining or valves. Clients with valve replacements are at increased risk, especially during procedures like dental work that may introduce bacteria into the bloodstream. Antibiotic prophylaxis is essential to prevent this potentially life-threatening condition.

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A nurse is caring for a client who is at risk for developing shock. Which of the following findings is the earliest indicator that this complication is occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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