The nurse is caring for a client with hypovolemic shock. Which new assessment finding indicates to the nurse that interventions are currently effective?
Oxygen saturation remains unchanged.
Core body temperature has increased to 99°F (37.2°C).
The client correctly states the month and year.
Serum lactate and serum potassium levels are declining.
The Correct Answer is D
A. While maintaining oxygen saturation is important, an unchanged SpO2 does not necessarily indicate that tissue perfusion and organ function are improving, which is the primary goal in treating hypovolemic shock.
B. A mild increase in temperature is not a reliable indicator of improved perfusion or effectiveness of interventions in hypovolemic shock. Temperature can fluctuate for many reasons and is not specific to hemodynamic improvement.
C. Improvement in mental status is a positive sign, but it may lag behind biochemical and hemodynamic recovery and alone does not provide the most objective evidence that interventions are working.
D. Serum lactate is a key marker of tissue hypoxia and poor perfusion. In hypovolemic shock, lactate rises due to anaerobic metabolism. Declining lactate indicates that tissue oxygen delivery is improving and perfusion is being restored. Similarly, correcting hypovolemia often stabilizes electrolyte imbalances, including potassium. Objective improvements in laboratory values provide clear evidence that fluid resuscitation, oxygen therapy, and other interventions are effective.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While skin color can indicate oxygenation status, it does not confirm tube placement. Cyanosis may appear late, and relying solely on skin color can delay recognition of incorrect placement.
B. Respiratory rate shows ventilatory patternbut cannot reliably confirm endotracheal tube position. A patient may breathe or be ventilated even if the tube is in the esophagus or mainstem bronchus.
C. Checking cuff inflation ensures a seal to prevent air leaks, but it does not indicate proper tracheal placement. An inflated cuff in the esophaguswould not prevent misplacement.
D. Auscultation of bilateral breath soundsover the lungs is a primary bedside assessmentfor confirming proper endotracheal tube placement. Absence of sounds on one side may indicate mainstem intubation, while no breath sounds with epigastric gurgling suggests esophageal placement. This assessment is immediate, noninvasive, and criticalbefore confirming with a chest x-ray.
Correct Answer is D
Explanation
A. While monitoring urine output is important in ARDS and shock to assess perfusion, it does not address the immediate life-threatening hypoxemiaand respiratory failure demonstrated by PaO2 51 mmHg and SaO2 76%.
B. Furosemide may be used to manage pulmonary edema in ARDS, but diuresis is not the first prioritywhen the patient is severely hypoxemic and at risk of respiratory arrest. Giving diuretics before securingthe airway could worsen hypoperfusion and oxygenation.
C.Prone positioning can improve oxygenation in ARDS and is an important intervention, but it cannot replace the need for airway managementin a patient with severe hypoxemia and hypercapnia.
D. The ABG results indicate severe hypoxemia (PaO2 51, SaO2 76%) and hypercapnia (PaCO2 58) with alkalemia (pH 7.56 likely from compensatory mechanisms or ventilatory pattern changes). These findings signal impending respiratory failure, making endotracheal intubation and mechanical ventilation the priorityto maintain oxygenation, ventilation, and prevent further organ dysfunction.
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