A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Heart rate 180/min

Motled skin

Hypokalemia

Blood pressure 115/68 mm Hg

Answer and Explanation

The Correct Answer is D

The correct answer is D. Blood pressure 115/68 mm Hg.

Choice A reason: Heart rate 180/min is incorrect because, although an increased heart rate is a compensatory mechanism, a rate of 180/min is excessively high and suggests a more severe stage of shock or other cardiac issues.

Choice B reason: Mottled skin is incorrect as it indicates poor perfusion seen in decompensated shock, where organ dysfunction begins to manifest, not in the compensatory stage.

Choice C reason: Hypokalemia, or low potassium levels, is incorrect because electrolyte imbalances are not typically a finding in the compensatory stage of shock. Normal potassium levels range from 3.5 to 5.0 mEq/L.

Choice D reason: Blood pressure 115/68 mm Hg is correct because it falls within the normal blood pressure range, which the body strives to maintain during the compensatory stage of shock through various mechanisms.

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Correct Answer is A

Explanation

Choice A: Fatigue is a manifestation that the nurse should identify as indicating the client is hypokalemic. Hypokalemia is a condition in which the blood potassium level is lower than normal, usually due to excessive loss of potassium through urine, sweat, or vomiting. Potassium is an electrolyte that is essential for nerve and muscle function, especially for the heart. Hypokalemia can cause muscle weakness, cramps, and fatigue, as well as cardiac arrhythmias and dysrhythmias.

Choice B: Dyspnea is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Dyspnea is a sensation of difficulty breathing or shortness of breath. Dyspnea can be caused by various conditions, such as asthma, chronic obstructive pulmonary disease (COPD), pneumonia, or pulmonary edema. Dyspnea is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause ﬂuid accumulation in the lungs and impair gas exchange.

Choice C: Oliguria is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Oliguria is a reduced urine output, usually less than 400 mL per day or 30 mL per hour. Oliguria can be caused by various conditions, such as dehydration, kidney failure, urinary tract obstruction, or shock. Oliguria is not directly related to hypokalemia, but it can be a sign of kidney damage or impairment, which can aﬀect electrolyte balance and ﬂuid volume.

Choice D: Pitting edema is not a manifestation that the nurse should identify as indicating the client is hypokalemic. Pitting edema is a swelling of the tissues that leaves an indentation when pressed with a finger. Pitting edema can be caused by various conditions, such as venous insufficiency, lymphedema, liver cirrhosis, or malnutrition. Pitting edema is not directly related to hypokalemia, but it can be a sign of heart failure, which can cause ﬂuid retention and overload in the body.

A. Remove both of the elastic bandages from the leg. B. Discharge the client. C. Obtain a prescription for the appropriate anti-venom. D. Obtain a prescription for pain medication.

Correct Answer is C

Explanation

Choice A: Removing the elastic bandages is not recommended. These bandages help slow the spread of venom by compressing the lymphatic vessels. Removing them could worsen the envenomation.

Choice B: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.

Choice C: This is the correct action. Antivenom treatment is crucial for serious snake envenomation. The sooner it can be administered, the better the outcome.

Choice D: While pain management is important, it is not the priority in this situation. Antivenom takes precedence over pain medication.

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A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

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