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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Hypertension is not an early sign of hemorrhage; instead, hypotension occurs as blood loss progresses.
B. Bradycardia is not an expected response; tachycardia is more common due to compensatory mechanisms.
C. Tachypnea is an early indicator of internal bleeding as the body attempts to compensate for decreased oxygen delivery by increasing respiratory rate.
D. Hyperthermia is not associated with hemorrhage; instead, hypothermia can occur with significant blood loss.

A. Gastric analysis B. Abdominal ultrasound C. Esophagogastroduodenoscopy (EGD) D. Stool culture

Correct Answer is C

Explanation

A) Incorrect. Gastric analysis is not commonly used to confirm the presence of blood in the stomach or identify the source of bleeding.

B) Incorrect. Abdominal ultrasound may be helpful in evaluating certain abdominal conditions but is not the primary test for diagnosing upper gastrointestinal bleeding.

C) Correct. Esophagogastroduodenoscopy (EGD) is a direct visualization procedure that uses a flexible endoscope to examine the esophagus, stomach, and duodenum. It allows for visualization of the source of bleeding and potential interventions like cauterization or sclerotherapy.

D) Incorrect. Stool culture is used to detect gastrointestinal infections but is not specific to diagnosing upper gastrointestinal bleeding.

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A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention should the nurse prioritize during the initial resuscitation phase?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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