The nurse is caring for a 52-year-old male patient with a bowel obstruction. Which of these signs would be the earliest indicator to the nurse that the patient is developing symptoms of shock?
Urine output 18 mL/hr.
Blood pressure 88/50 mmHg.
Lethargy.
Pulse 110 bpm.
The Correct Answer is A
Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.
Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.
Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.
Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Cool, dry skin is not typically associated with a panic attack, which often involves symptoms like sweating due to the fight-or-flight response.
Choice B reason: Chest pain is a common symptom of panic attacks, often leading individuals to believe they are having a heart attack.
Choice C reason: Pallor, or paleness, may occur during a panic attack, but it is not as common as other symptoms like chest pain.
Choice D reason: Bradycardia, or slow heart rate, is not characteristic of a panic attack; tachycardia, or fast heart rate, is more common.
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Deep breathing and coughing exercises help clear the lungs and prevent atelectasis, a common postoperative respiratory complication.
Choice B reason: Incentive spirometry encourages patients to take deep breaths, which can help keep the lungs clear of mucus and prevent pneumonia.
Choice C reason: Leg exercises improve circulation and can help prevent blood clots, which can lead to pulmonary embolism, another serious respiratory complication.
Choice D reason: Early ambulation, or getting the patient moving as soon as possible after surgery, is crucial for preventing respiratory complications by promoting circulation and lung expansion.
Choice E reason: Hand squeezes are not directly related to preventing respiratory complications; they are more associated with preventing circulatory complications.
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