A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
Decrease in the urinary output from 50 mL to 30 mL per hour.
Increase in the heart rate from 88 to 110/min.
Decrease in the respiratory rate from 20 to 16/min.
Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).
The Correct Answer is B
A. A decrease in urinary output can be a sign of decreased blood volume but is less immediate than changes in heart rate.
B. An increase in the heart rate is a common compensatory response to hypovolemia as the body attempts to maintain adequate perfusion to vital organs.
C. A decrease in the respiratory rate is not typically associated with hypovolemic shock; rather, respiratory rate may increase due to compensatory mechanisms.
D. An increase in temperature is not a specific indicator of hypovolemic shock; it could be related to infection or inflammation rather than immediate hypovolemia.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Pain severity is important to assess but is secondary to ensuring the client's airway is clear and unobstructed.
B. Wound drainage is relevant for detecting potential complications but is not as critical as ensuring airway patency.
C. Tissue integrity is important for wound healing but does not take precedence over checking the airway immediately after surgery.
D. Airway patency is the priority assessment because a partial laryngectomy involves the airway, and ensuring it is open and functioning is crucial for adequate breathing.
Correct Answer is C
Explanation
A. Handrails in the bathroom are a safety feature designed to prevent falls, which is beneficial for clients with decreased vision and other mobility issues.
B. Using a microwave for cooking is generally safe and convenient, especially for clients with decreased vision, as it reduces the need for handling hot pots and pans.
C. Scatter rugs can be a significant safety risk as they may cause tripping hazards, particularly for individuals with vision problems who may not see them clearly.
D. Electrical cords placed along the walls are less of a risk compared to scatter rugs. While they should be properly managed to avoid tripping hazards, they do not pose as immediate a risk as scattered rugs.
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