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 D

Explanation

A. Controlling impulsive behavior is more commonly associated with right hemispheric strokes due to impaired judgment and spatial awareness.
B. Improving left-side motor function would be a goal for a right hemispheric CVA because motor deficits occur on the side opposite the brain injury.
C. Loss of depth perception is typically a problem with right hemispheric damage affecting spatial-perceptual skills.
D. Left hemispheric strokes often affect language centers, leading to aphasia. Therefore, a primary rehabilitation goal is improving communication abilities.

Correct Answer is ["10","472"]

Explanation

Both legs account for approximately 36% of total body surface area (18% per leg × 2).

Convert weight to kilograms: 160 lbs ÷ 2.2 = 72.73 kg

Using the Parkland formula:
4 mL × 72.73 kg × 36 = 10,472 mL of fluid for the first 24 hours

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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?

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Naxlex Comprehensive Predictor Exams

A nurse at a rehabilitation center is planning care for a client who had a left hemispheric cerebrovascular accident (CVA) 3 weeks ago. Which of the following goals should the nurse include in the client's rehabilitation program?

Correct Answer is D

Explanation

A nurse is caring for a client weighing 160 lbs. who sustained burn injuries to both legs completely. There's a pending order for 0.9% sodium chloride. How much fluid is the client to receive for the first 24 hours? (Round to the nearest whole number.)

Correct Answer is ["10","472"]

Explanation

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