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 D

Explanation

A) Incorrect. While the respiratory rate is an important vital sign to monitor, it does not directly indicate the effectiveness of a blood transfusion.

B) Incorrect. Blood pressure is a critical vital sign, but it is not specific to assessing the effectiveness of a blood transfusion.

C) Incorrect. Urinary output is essential for assessing kidney function and fluid balance, but it does not directly reflect the impact of a blood transfusion.

D) Correct. Monitoring the hemoglobin level is crucial to determine if the blood transfusion has been effective in increasing the client's red blood cell count and improving oxygen-carrying capacity.

A. Bradycardia B. Hypotension C. Pallor D. Restlessness

Correct Answer is D

Explanation

A) Incorrect. Bradycardia is not typically an early clinical manifestation of hemorrhage. The body may initially compensate for the blood loss by increasing heart rate (tachycardia).

B) Incorrect. Hypotension may occur later in the course of hemorrhage as blood loss progresses, but it is not an early manifestation.

C) Incorrect. Pallor (pale skin) may occur later as a result of decreased blood volume, but it is not an early sign.

D) Correct. Restlessness and anxiety are early manifestations of hemorrhage, reflecting the body's compensatory response to maintain perfusion in the early stages of blood loss.

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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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Explanation

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Correct Answer is D

Explanation

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