The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock?

Narrowed pulse pressure, presence of 3+ femoral pulses, apneic episodes.

Widening pulse pressure, muffled heart sounds, presence of atrial gallop.

Increased heart rate, lowered systolic reading, peripheral extremity mottling.

Irregular heart rate, elevated diastolic reading, increased respiratory rate.

Answer and Explanation

The Correct Answer is C

A. Narrowed pulse pressure, presence of 3+ femoral pulses, apneic episodes. Narrowed pulse pressure is consistent with hypovolemic shock, but 3+ femoral pulses are not expected, as shock leads to weak, thready pulses due to reduced perfusion. Apneic episodes typically occur in the late stages of shock, not in the early or progressive stages.
B. Widening pulse pressure, muffled heart sounds, presence of atrial gallop. A widening pulse pressure and muffled heart sounds are more indicative of cardiac tamponade, not hypovolemic shock. Hypovolemic shock is characterized by a narrowing pulse pressure due to a drop in systolic blood pressure while diastolic pressure remains relatively stable.
C. Increased heart rate, lowered systolic reading, peripheral extremity mottling. Tachycardia is an early compensatory response to hypovolemia as the body attempts to maintain cardiac output. As shock progresses, systolic blood pressure drops due to inadequate circulating volume. Peripheral extremity mottling occurs as the body shunts blood to vital organs, reducing perfusion to the skin. These signs are characteristic of progressive hypovolemic shock.
D. Irregular heart rate, elevated diastolic reading, increased respiratory rate. An irregular heart rate is not a primary indicator of hypovolemic shock. While respiratory rate increases in response to decreased oxygen delivery, an elevated diastolic reading is uncommon, as diastolic pressure tends to stay stable or decrease slightly with ongoing hypovolemia.

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Correct Answer is B

Explanation

A. Notify healthcare provider (HCP) of the symptoms and administer a PRN pain medication. While notifying the HCP is necessary, administering pain medication does not address the underlying cause of the client’s acute chest pain and difficulty breathing. These symptoms suggest a possible pulmonary embolism (PE), a life-threatening complication after orthopedic surgery. Immediate supportive interventions should be initiated before notifying the provider.
B. Increase the client's IV flow rate and start low-flow oxygen. The client is experiencing acute respiratory distress, which could indicate a pulmonary embolism (PE), a fat embolism, or another postoperative complication. Providing oxygen helps improve oxygenation and reduce hypoxia, while increasing the IV flow rate helps maintain perfusion and prevent shock. These immediate interventions support vital functions while preparing for further medical management.
C. Position the client on the left side while immobilizing the affected leg. This position is used in air embolism management, not pulmonary embolism. In suspected PE, the priority is to optimize oxygenation and circulation rather than repositioning. The affected leg should be immobilized to prevent further embolization, but this is not the first priority.
D. Take the client's vital signs and auscultate all lung sounds. While assessing the client’s vital signs and lung sounds is important, intervention should not be delayed. The priority is to support oxygenation and circulation immediately, as PE can rapidly lead to hypoxia, hemodynamic instability, or cardiac arrest. Assessment should be done concurrently with emergency interventions.

A. View the rhythm in another chest lead. B. Begin chest compressions at a rate of 120 times a minute. C. Auscultate all chest fields for muffled lung sounds. D. Observe for swelling at the fracture site.

Correct Answer is B

Explanation

A. View the rhythm in another chest lead. While verifying the rhythm in another lead may help confirm the accuracy of the monitor, it does not address the immediate absence of a pulse and respirations. The client is in pulseless electrical activity (PEA), which requires immediate intervention rather than rhythm verification.
B. Begin chest compressions at a rate of 120 times a minute. The client has no palpable carotid pulse and no spontaneous respirations despite a sinus rhythm on the monitor, indicating pulseless electrical activity (PEA). PEA is a form of cardiac arrest where the heart shows electrical activity but fails to generate effective circulation. Immediate high-quality chest compressions are essential to maintain perfusion while addressing the underlying cause, such as hypovolemia or tension pneumothorax.
C. Auscultate all chest fields for muffled lung sounds. While assessing for muffled lung sounds may help detect conditions such as tension pneumothorax or hemothorax, it should not delay the initiation of CPR. Once compressions are started, the underlying cause of PEA can be investigated.
D. Observe for swelling at the fracture site. Swelling at the fracture site may indicate bleeding or compartment syndrome, but assessing the fracture should not take priority over initiating CPR. If hemorrhage is suspected as a cause of PEA, rapid fluid resuscitation should be initiated after starting chest compressions.

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The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock?

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