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 C

Explanation

A. Place a cooling blanket on the client. A temperature of 100°F (37.8°C) is only mildly elevated and does not require active cooling. The priority concern is hemodynamic instability due to hypovolemia, not fever management. Cooling blankets are typically used for high fevers (≥ 102°F or 38.9°C).
B. Administer an antipyretic agent. While fever may indicate postoperative infection or inflammatory response, the client’s most critical issue is hypotension and low urine output, suggesting hypovolemia or early shock. Treating the underlying cause (fluid loss) is more urgent than giving an antipyretic.
C. Give a 500 mL IV fluid bolus challenge. The client has tachycardia (132 bpm), hypotension (88/65 mm Hg), and oliguria (10 mL/hour), all of which suggest hypovolemic shock, a common postoperative complication. A fluid bolus (typically 500–1000 mL of isotonic crystalloid such as normal saline or lactated Ringer’s) is the first-line treatment to restore intravascular volume, improve blood pressure, and increase urine output.
D. Titrate IV vasopressor for systolic less than 80. Vasopressors (e.g., norepinephrine) are not the first-line treatment for hypovolemic shock. Fluids should be administered first to correct volume loss before considering vasopressors. If hypotension persists despite adequate fluid resuscitation, vasopressors may be initiated.

A. Elevate the head of the bed and provide a pillow under the client's head. B. Suction the endotracheal tube every 15 minutes to reduce choking. C. Intersperse treatments and nursing care with frequent rest periods. D. Change positions frequently while providing basic nursing care.

Correct Answer is C

Explanation

A. Elevate the head of the bed and provide a pillow under the client's head. While elevating the head of the bed to 30 degrees can help reduce ICP by promoting venous drainage, placing a pillow under the head may cause neck flexion, which can obstruct venous outflow and worsen intracranial pressure. Instead, the head should be maintained in a neutral midline position without excessive flexion or extension.
B. Suction the endotracheal tube every 15 minutes to reduce choking. Frequent suctioning can increase ICP due to coughing and vagal stimulation. Suctioning should be performed only as needed and using minimized suction duration to prevent sudden rises in intracranial pressure.
C. Intersperse treatments and nursing care with frequent rest periods. Clustering too many nursing interventions together can overstimulate the client and cause spikes in ICP. Providing adequate rest periods between activities such as repositioning, suctioning, and assessments allows intracranial pressure to return to baseline levels, helping to prevent sustained increases.
D. Change positions frequently while providing basic nursing care. Frequent repositioning can cause sudden fluctuations in ICP, especially if movements are abrupt or cause venous obstruction. Turning the client slowly and maintaining the head in a neutral position is recommended to avoid exacerbating intracranial hypertension.

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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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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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