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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Document that the client is experiencing a paced rhythm. A pacemaker spike before each QRS complex indicates that the pacemaker is functioning properly and triggering ventricular depolarization as intended. Since the client is 24 hours postoperative from a pacemaker insertion, this is an expected finding and should be documented accordingly.
B. Reposition the ECG leads and obtain another recording. If the ECG showed artifact, lead displacement, or interference, repositioning the leads might be appropriate. However, the presence of consistent pacemaker spikes before each QRS complex suggests proper pacemaker function rather than a lead issue.
C. Assess the client for symptoms of decreased cardiac output. A paced rhythm is expected after pacemaker insertion and does not necessarily indicate hemodynamic instability. While assessment is always important, there is no indication that the client is experiencing decreased cardiac output symptoms such as hypotension, dizziness, or altered mental status.
D. Notify the healthcare provider (HCP) of the telemetry recording. Routine paced rhythms do not require immediate provider notification unless there are malfunctions such as failure to capture, failure to sense, or failure to pace. Since the pacemaker is functioning appropriately, notifying the HCP is unnecessary.

A. Decreased cardiac output. B. Ineffective airway clearance. C. Ineffective peripheral tissue perfusion. D. Deficient fluid volume.

Correct Answer is A

Explanation

A. Decreased cardiac output. Central venous pressure (CVP), also called right atrial pressure (RAP), reflects right ventricular preload and overall fluid status. An increasing CVP indicates fluid overload or impaired right ventricular function, both of which can lead to decreased cardiac output. Conditions such as right heart failure, pulmonary hypertension, or excessive fluid resuscitation can cause elevated CVP, reducing the heart’s ability to pump effectively and leading to poor systemic circulation.
B. Ineffective airway clearance. Airway clearance is not directly related to CVP measurements. While severe pulmonary conditions like ARDS or COPD can contribute to cardiac strain and right heart failure, the primary mechanism for rising CVP is cardiac dysfunction or fluid overload, not airway obstruction.
C. Ineffective peripheral tissue perfusion. Although decreased cardiac output can impair tissue perfusion, this choice is too broad. Increased CVP specifically reflects right-sided heart function and preload, making decreased cardiac output the more precise diagnosis related to the pathophysiologic mechanism.
D. Deficient fluid volume. A low CVP is associated with hypovolemia and fluid deficits, while an increasing CVP suggests fluid overload, heart failure, or venous congestion. Deficient fluid volume would cause a downward trend in CVP, not an increase.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses the telemetry monitor of a client who is 24 hours postoperative from having a permanent pacemaker insertion. The nurse observes that a pacemaker spike is present before each QRS complex in lead II of the electrocardiogram (ECG). Which intervention should the nurse implement?

Correct Answer is A

Explanation

The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

Correct Answer is A

Explanation

A client has been treated for uncontrolled atrial fibrillation with cardioversion. Following the cardioversion, which assessment finding indicates to the nurse that the desired outcome was achieved?

A client who had gastric bypass surgery 3 days ago is admitted to the intensive care unit (ICU) with shortness of breath and chest pain. The client has a 100% nonrebreather mask with an oxygen saturation of 88%. Which intervention should the nurse implement?

The nurse assesses a client postoperatively who has an arterial line in the right radial artery. Assessment findings include pallor, paresthesia, and slow capillary refill in the client's right-hand fingers. Which action should the nurse take?