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).

Answer and Explanation

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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Correct Answer is A

Explanation

A. A WBC count of 1500/mm3 is significantly low (normal range is 4500-11000/mm3) and indicates neutropenia, placing the client at high risk for infection. This finding should be reported to the provider immediately.
B. An RBC count of 5 million/mm3 is within the normal range for females (4.2-5.4 million/mm3) and does not indicate an immediate concern in the context of chemotherapy.
C. Platelet count of 155,000/mm3 is on the lower end of the normal range (150,000-450,000/mm3) but does not pose an immediate risk compared to neutropenia.
D. A hemoglobin level of 12 g/dL is within the normal range for females (12-16 g/dL) and does not require urgent reporting.

A. Temperature B. Blood pressure C. Pain level D. Adalimumab frequency E. Heart sounds F. WBC count G. Urinalysis H. Hgb & Hct

Correct Answer is ["A","B","C","F","G"]

Explanation

A. Temperature: The client has a fever (39.3°C/102.8°F) indicating a potential infection or inflammatory process. This requires immediate follow-up to address the underlying cause of the fever.

B. Blood pressure: The client’s blood pressure is low (84/58 mm Hg on admission and 88/58 mm Hg current), suggesting possible shock or severe dehydration. This finding requires immediate assessment and intervention.

C. Pain level: The client reports increasing back and suprapubic pain, which could be related to a urinary tract infection or other serious condition. Addressing pain and its cause is critical.

D. Adalimumab frequency: The current medication schedule for Adalimumab is less urgent compared to the acute findings. The frequency of this medication does not require immediate follow-up in this context.

E. Heart sounds: No dysrhythmias were noted on the cardiac monitor, so this finding does not require immediate follow-up at this time.

F. WBC count: The WBC count is elevated with leucocyte esterase positive, indicating an infection. This warrants immediate attention to diagnose and treat the infection.

G. Urinalysis: The urinalysis shows cloudy appearance, foul odor, and alkaline pH with positive leucocyte esterase, suggesting a urinary tract infection. This requires immediate follow-up to start appropriate treatment.

H. Hgb & Hct: While important, these values are not provided in the current context. The immediate concerns are more focused on the acute symptoms and signs provided.

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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?

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