After receiving the change-of-shift report, which client does the nurse assess first?

Choice A reason: Decreased cardiac output is a hallmark of cardiogenic shock, as the heart fails to pump adequately. This aligns with shock pathophysiology, making it a correct manifestation the nurse would expect when assessing a client for cardiogenic shock in a clinical setting.

Choice B reason: Increased pulse rate occurs in cardiogenic shock as the body compensates for low cardiac output. This aligns with cardiovascular assessment findings, making it a correct manifestation the nurse would identify in a client experiencing cardiogenic shock during evaluation.

Choice C reason: Postural hypotension is more typical of hypovolemic or orthostatic issues, not cardiogenic shock, which features weak pulses. Weak thready pulse is correct, making this incorrect, as it’s not a primary sign of cardiogenic shock in the nurse’s assessment.

Choice D reason: Bounding pulse suggests hyperdynamic circulation, not cardiogenic shock, where perfusion is poor. Weak thready pulse is typical, making this incorrect, as it does not reflect the compromised cardiac output expected in the nurse’s evaluation of cardiogenic shock.

Choice E reason: Weak thready pulse indicates poor perfusion in cardiogenic shock due to reduced cardiac output. This aligns with peripheral vascular assessment, making it a correct manifestation the nurse would expect when assessing a client in cardiogenic shock.

Choice F reason: Hypertension is not typical in cardiogenic shock, which often presents with hypotension due to pump failure. Pink frothy sputum is correct, making this incorrect, as it contradicts the hemodynamic profile in the nurse’s assessment of cardiogenic shock.

Choice G reason: Capillary refill greater than 3 seconds reflects poor perfusion in cardiogenic shock, consistent with low cardiac output. This aligns with peripheral assessment findings, making it a correct manifestation the nurse would note in a client with cardiogenic shock.

Choice H reason: Capillary refill less than 3 seconds suggests normal perfusion, not cardiogenic shock, where refill is delayed. Greater than 3 seconds is correct, making this incorrect, as it does not align with the poor perfusion in cardiogenic shock assessment.

Choice I reason: Pink frothy sputum indicates pulmonary edema, common in cardiogenic shock due to left heart failure. This aligns with respiratory assessment findings, making it a correct manifestation the nurse would expect in a client with cardiogenic shock.

Choice A reason: Checking urinary specific gravity monitors DI control but is less critical than detecting fluid retention from desmopressin, which can cause hyponatremia. Daily weighing identifies weight gain, making this incorrect, as it’s secondary to the nurse’s priority teaching on preventing serious drug-related complications.

Choice B reason: Monitoring blood pressure is relevant for cardiovascular health but not the primary concern with desmopressin, which risks fluid overload. Daily weighing detects this, making this incorrect, as it’s less specific than the nurse’s teaching to monitor for weight gain in DI treatment.

Choice C reason: Blood glucose monitoring is unrelated to desmopressin or DI, which affects water balance, not glucose. Weighing daily addresses fluid retention, making this incorrect, as it’s irrelevant compared to the nurse’s priority teaching on managing desmopressin’s fluid-related side effects in DI.

Choice D reason: Daily weighing and reporting weight gain is the priority teaching, as desmopressin can cause fluid retention, leading to hyponatremia. This aligns with DI therapy safety, making it the correct teaching to prevent complications, ensuring the client monitors for this critical adverse effect of desmopressin.