The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?
Increased urine output
Decreased heart rate
Hyperactive bowel sounds
Cool, clammy skin
The Correct Answer is D
Rationale:
A. Increased urine output is not expected in the compensatory stage of shock. Early in shock, the body activates the renin-angiotensin-aldosterone system to conserve fluid, resulting in decreased urine output (oliguria).
B. Decreased heart rate is not typical in compensatory shock. The body usually responds to early hypovolemia with tachycardia to maintain cardiac output and perfusion to vital organs.
C. Hyperactive bowel sounds are not a hallmark of early shock. In fact, perfusion to the gastrointestinal system is reduced during shock, which may lead to hypoactive or diminished bowel sounds.
D. Cool, clammy skin is an expected finding in the compensatory stage of shock. The body shunts blood away from the skin and non-vital organs to maintain perfusion of vital organs (brain, heart, lungs). Peripheral vasoconstriction reduces skin perfusion, causing the skin to feel cool and moist due to sympathetic nervous system activation and increased catecholamines.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. 3.3 mL would deliver approximately 742 mg, which is far above the prescribed dose.
B. 1.1 mL provides approximately 250 mg, matching the provider’s order.
First, identify the ordered dose and the available concentration.
Ordered dose = 250 mg
Available concentration = 225 mg per 1 mL
Use the medication calculation formula:
Amount to administer (mL) = Ordered dose ÷ Concentration
250 mg ÷ 225 mg/mL = 1.11 mL, which rounds to 1.1 mL
C. 2.5 mL refers to the reconstitution volume, not the amount to administer.
D. 1 mL would deliver only 225 mg, which is less than the prescribed dos
Correct Answer is B
Explanation
Rationale:
A. Inserting an indwelling urinary catheter may be necessary for accurate monitoring of urine output in burn patients, but it is not the immediate priority in the emergency assessment. Urinary monitoring is important after airway and breathing have been assessed and stabilized.
B. Inspecting the mouth for signs of inhalation injury is the priority action. Burns involving the face, neck, and chest place the client at high risk for airway compromise from edema, soot, or inhaled heat and smoke. Airway management follows the “Airway, Breathing, Circulation” (ABC) approach, and early identification of inhalation injury can be life-saving.
C. Administering intravenous pain medication is important for comfort and to reduce stress response, but it does not take priority over assessing and securing the airway in a burn patient. Pain management should be initiated after life-threatening conditions are addressed.
D. Drawing blood for a CBC helps assess hemoglobin, hematocrit, and infection risk, but laboratory evaluation is not an immediate life-saving intervention. It is secondary to airway assessment and stabilization.
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