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 C
Explanation
Choice A reason: Provision of home care is not part of the immediate postoperative phase described during preoperative teaching.
Choice B reason: The decision for surgery until transfer to surgery is part of the preoperative phase, not the postoperative phase.
Choice C reason: Admission to the Post Anesthesia Care Unit (PACU) until recovery is the correct description of the postoperative phase, where the patient is monitored as they recover from anesthesia.
Choice D reason: Transfer to surgery until transfer to PACU describes the transition from preoperative to intraoperative phases, not the postoperative phase.
Correct Answer is C
Explanation
Choice A reason: Fear of heights is known as acrophobia, not agoraphobia.
Choice B reason: Fear of blood is known as hemophobia, not agoraphobia.
Choice C reason: Agoraphobia is the fear of being in situations where escape might be difficult or that help wouldn't be available if things go wrong, such as shopping in a large mall.
Choice D reason: Fear of speaking is known as glossophobia, not agoraphobia.
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