A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention should the nurse prioritize during the initial resuscitation phase?
Administering intravenous (IV) fluids rapidly.
Administering supplemental oxygen.
Monitoring the client's blood glucose levels.
Performing neurological assessments.
The Correct Answer is A
A) Correct. The priority during the initial resuscitation phase of hypovolemic shock is to replace lost intravascular volume promptly. Administering IV fluids rapidly is crucial to improve tissue perfusion and blood pressure.
B) Incorrect. While administering supplemental oxygen is important for tissue oxygenation, it is not the primary intervention during the initial resuscitation phase.
C) Incorrect. Monitoring blood glucose levels is important for overall assessment but is not the priority during the initial resuscitation phase of hypovolemic shock.
D) Incorrect. Neurological assessments are essential but may not be the immediate priority during the initial resuscitation phase of hypovolemic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Incorrect. A neurological assessment is important to evaluate the client's central nervous system function, but it is not directly related to identifying bleeding sources.
B) Correct. A skin integrity assessment is essential to identify potential external bleeding sources, such as cuts, bruises, or petechiae, which may indicate underlying bleeding disorders.
C) Incorrect. While an abdominal assessment is crucial in identifying internal bleeding in the abdominal area, it is not the most essential assessment to identify bleeding sources overall.
D) Incorrect. A respiratory assessment is important for assessing oxygenation and respiratory status, but it is not the primary assessment to identify bleeding sources.
Questions
Correct Answer is B
Explanation
A) Incorrect. Swelling and bruising around the wound are common signs of external bleeding and do not directly indicate internal bleeding.
B) Correct. Cool and pale skin in the extremities may be indicative of vasoconstriction and reduced blood flow, which can occur in response to internal bleeding.
C) Incorrect. Blood oozing from the wound site is a typical sign of external bleeding and does not necessarily indicate internal bleeding.
D) Incorrect. Visible blood clot formation at the wound site is a normal part of the body's hemostatic response to control external bleeding and does not directly suggest internal bleeding.
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