The emergency department nurse is assessing a patient who is in the compensatory stage of hypovolemic shock. Which manifestations does the nurse expect? Select all that apply.

Elevated heart rate.

Elevated respiratory rate.

Decreased pulse rate.

Decrease systolic blood pressure.

Decreased urine output.

Bilateral crackles in the lung bases.

Answer and Explanation

Correct Answer : A,B,D,E

These manifestations occur as compensatory mechanisms in response to decreased blood volume and compromised tissue perfusion. The body attempts to compensate for the inadequate circulating volume by increasing heart rate (A) and respiratory rate (B) to enhance oxygen delivery.
D. The decreased systolic blood pressure (D) is a result of decreased cardiac output and vasoconstriction in an attempt to maintain perfusion to vital organs.
E. The decreased urine output (E) is a result of decreased renal perfusion due to decreased blood volume.
C. Decreased pulse rate in (option C) is incorrect because it is not typically seen in the compensatory stage of hypovolemic shock. The body tries to increase heart rate to maintain cardiac output and compensate for the decreased blood volume.
F. Bilateral crackles in (option F) is incorrect because the lung bases are more commonly associated with conditions such as pulmonary edema or fluid overload, rather than the compensatory stage of hypovolemic shock.
It's important to note that the manifestations of shock can vary depending on individual patient factors and the underlying cause of shock. Therefore, a comprehensive assessment and clinical judgment are necessary to fully evaluate the patient's condition.

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Correct Answer is B

Explanation

A. Oxygen saturation of 92% in (option A) is incorrect because While an oxygen saturation of 92% is suboptimal and may require intervention, it may not have the same immediate implications as low blood pressure. The healthcare provider should be informed, but addressing the blood pressure takes priority.
B. Skin cool and clammy in (option B) is correct because Cool and clammy skin is often associated with inadequate peripheral perfusion, which is a characteristic of septic shock.

C. Septic shock is characterized by systemic inflammation, vasodilation, and hypotension. Inadequate blood pressure is a significant concern in septic shock as it indicates poor tissue perfusion and compromised organ function. However, the mean arterial pressure is till acceptable.
D. Heart rate of 118 beats/minute in (option D) is incorrect because: Tachycardia is a common finding in septic shock and reflects the body's compensatory response to maintain cardiac output. While it is a significant finding, low blood pressure takes precedence in terms of urgency.

A. Mean arterial pressure is 55 mm Hg. B. Systemic vascular resistance (SVR) is elevated. C. Pulmonary artery wedge pressure (PAWP) is low. D. Heart rate is 58 beats/min.

Correct Answer is D

Explanation

Norepinephrine is a potent vasoconstrictor and inotropic agent commonly used to increase blood pressure in cases of hypotension or shock. However, if the infusion rate is too high, it can lead to excessive vasoconstriction and potentially compromise organ perfusion.
A heart rate of 58 beats/min suggests bradycardia, which can be an indication of excessive vasoconstriction caused by a high dose or rate of norepinephrine infusion. Excessive vasoconstriction can reduce cardiac output and worsen tissue perfusion.
A. Mean arterial pressure is 55 mm Hg in (option A) is incorrect because A mean arterial pressure of 55 mm Hg may be within an acceptable range for a patient receiving norepinephrine infusion, depending on the patient's baseline blood pressure and clinical condition.
B. Systemic vascular resistance (SVR) is elevated in (option B) is incorrect because An elevated SVR indicates increased peripheral vascular resistance and can be a desired effect of norepinephrine infusion to improve blood pressure and perfusion.
C. Pulmonary artery wedge pressure (PAWP) is low in (option C) which is incorrect because A low PAWP may indicate decreased left ventricular preload, which can be a desired effect of norepinephrine infusion to reduce fluid overload in certain clinical conditions.
It is important for the nurse to carefully monitor the patient's hemodynamic parameters, including blood pressure, heart rate, and organ perfusion when titrating norepinephrine infusion to ensure optimal dosing and minimize potential adverse effects. If concerns arise regarding the infusion rate, the healthcare provider should be promptly notified for further evaluation and adjustment of the treatment plan.

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The emergency department nurse is assessing a patient who is in the compensatory stage of hypovolemic shock. Which manifestations does the nurse expect? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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