The nurse is assessing a client who is in shock. Which of the following findings would indicate to the nurse that the client is entering an irreversible stage?

paCO2 of 45 Hg

Respirations 30/min

Urine output 15 ml/hr

Blood pressure of 100 mm Hg systolic

Answer and Explanation

The Correct Answer is C

A. PaCO₂ of 45 mm Hg is incorrect because 45 mm Hg is at the upper limit of normal (normal 35–45 mm Hg). In early shock, clients often hyperventilate, causing a decreased PaCO₂. A value of 45 mm Hg alone does not specifically indicate irreversible shock.

B. Respirations 30/min is incorrect because tachypnea is a compensatory mechanism seen in the early (compensatory) stage of shock. The body attempts to improve oxygen delivery by increasing respiratory rate. This finding alone does not indicate irreversible shock.

C. Urine output 15 mL/hr is correct because severely decreased urine output indicates significant renal hypoperfusion and possible acute kidney injury. In the irreversible (refractory) stage of shock, prolonged tissue hypoxia leads to organ failure. Oliguria (less than 30 mL/hr in adults) is a critical sign of worsening shock, and 15 mL/hr reflects severe compromise and progression toward multi-organ failure.

D. Blood pressure of 100 mm Hg systolic is incorrect because although this may be slightly low depending on baseline, it does not necessarily indicate irreversible shock. In early shock, blood pressure may remain near normal due to compensatory vasoconstriction. Profound, persistent hypotension despite interventions is more consistent with the irreversible stage.

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Correct Answer is A

Explanation

A. In an unconscious patient, airway and breathing take priorityaccording to the ABC (Airway, Breathing, Circulation) approachin emergency care. Even if the patient is breathing spontaneously, the nurse must assess for adequate oxygenation, airway patency, and signs of respiratory compromisebefore addressing other interventions. Immediate identification of airway obstruction or inadequate breathing can be life-saving.

B. Incorrect as the first action. While IV access is important for fluid resuscitation or medication administration, it does not take priority over ensuring airway and effective breathing, which are immediately life-sustaining.

C. Incorrect as the first action. A full physical assessment is important for identifying injuries, but airway and breathing must be addressed first. Removing clothing can occur after the patient is stabilized.

D. Incorrect as the first action. Assessing LOC is important to monitor neurological status, but it does not take priority over ensuring the patient can maintain adequate ventilation and oxygenation. LOC assessment can be done simultaneously or immediately after securing airway and breathing.

A. localized infiltrate B. enlargement of the heart C. white-out infiltrates bilaterally D. hyperinflation of lungs

Correct Answer is C

Explanation

A. Localized infiltrates indicate a focal process, such as bacterial pneumonia or aspiration in a single lobe. ARDS affects the lungs diffusely, so a localized pattern would not support the diagnosis.

B. Cardiomegaly is associated with cardiogenic pulmonary edema, where heart failure causes fluid accumulation in the lungs. In ARDS, the pulmonary edema is non-cardiogenic, and the heart size is typically normal.

C. In ARDS, the alveoli fill with fluid, protein, and inflammatory cells, causing widespread opacification on chest x-ray. This appears as bilateral, patchy, or confluent “white-out” infiltrates, indicating severe alveolar involvementand impaired oxygenation. These findings correlate with the patient’s rapidly worsening hypoxemia and respiratory distress.

D. Hyperinflation is characteristic of obstructive airway diseaseslike COPD or asthma, where air is trapped in the lungs. In ARDS, the lungs are stiff and noncompliant, so hyperinflation does not occur.

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The nurse is assessing a client who is in shock. Which of the following findings would indicate to the nurse that the client is entering an irreversible stage?

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Naxlex Comprehensive Predictor Exams

What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED?

Correct Answer is A

Explanation

A patient has been hospitalized in the ICU for a near drowning event. The patient's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?

Correct Answer is C

Explanation

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