A nurse is caring for a client who returns to the intensive care unit after a mass resection from the gastrointestinal tract. The client experienced bleeding throughout the procedure. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Increase in the heart rate from 90 to 120/min.

Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).

Decrease in the urinary output from 120 mL to 115 mL per hour.

Decrease in the respiratory rate from 24 to 16/min.

Answer and Explanation

The Correct Answer is A

A. Tachycardia is an early compensatory sign of hypovolemic shock due to decreased circulating volume.
B. Increased temperature suggests infection or inflammation, not hypovolemic shock.
C. A slight decrease in urine output from 120 to 115 mL/hr is not significant; oliguria would be a more concerning sign.
D. A decrease in respiratory rate is not typical of hypovolemic shock, which usually causes tachypnea.

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Correct Answer is B

Explanation

A. Evaluating for other injuries is important but not the immediate priority.
B. If no cervical spine injury is suspected, the head tilt-chin lift is the recommended method to open the airway first in an apneic client.
C. The jaw-thrust maneuver is used when cervical spine injury is suspected to avoid neck movement.
D. Applying a rigid cervical collar is not necessary if no cervical injury is suspected.

A. Open the airway using a jaw-thrust maneuver. B. Determine effectiveness of ventilator efforts. C. Establish IV access. D. Perform a Glasgow Coma Scale assessment. E. Remove clothing for a thorough assessment.

Correct Answer is ["A","B","C","D","E"]

Explanation

A (Airway): Open the airway using a jaw-thrust maneuver is the first action to ensure the airway is patent, especially important in trauma to avoid cervical spine injury.

B (Breathing): Determine effectiveness of ventilator efforts comes next to assess if the client is ventilating adequately.

C (Circulation): Establish IV access is part of restoring and maintaining circulation, allowing for fluid resuscitation or medication administration.

D (Disability): Perform a Glasgow Coma Scale assessment evaluates neurological function to determine the level of consciousness.

E (Exposure): Remove clothing for a thorough assessment ensures the nurse can identify all injuries and prevent missing any life-threatening conditions.

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A nurse is caring for a client who has a pneumothorax.

Exhibits

A nurse is reviewing the client's medical record. Which of the following prescriptions should the nurse anticipate for a client who has a pneumothorax?

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

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A nurse is caring for a client who returns to the intensive care unit after a mass resection from the gastrointestinal tract. The client experienced bleeding throughout the procedure. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","D","E"]

Explanation

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