The nurse is caring for a patient recovering from surgery. What action should the nurse perform to prevent the onset of hypovolemic shock?

Elevate the head of the bed

Provide immediate pain relief

Monitor intake and output

Practice careful and consistent hand hygiene

Answer and Explanation

The Correct Answer is C

Choice A reason:

Elevating the head of the bed is a common practice in patient care but is not directly related to preventing hypovolemic shock. This action can help with respiratory comfort and drainage but does not address fluid balance or blood volume, which are critical in preventing hypovolemic shock.

Choice B reason:

Providing immediate pain relief is important for patient comfort and recovery but does not directly prevent hypovolemic shock. While controlling pain can reduce stress on the body, it does not address the fluid and blood volume concerns central to preventing hypovolemic shock.

Choice C reason:

Monitoring intake and output is crucial in preventing hypovolemic shock, especially in postoperative patients. This helps to ensure that fluid balance is maintained, and any significant losses (e.g., through bleeding, vomiting, or excessive drainage) are promptly addressed. Accurate monitoring allows for early intervention to prevent hypovolemic shock.

Choice D reason:

Practicing careful and consistent hand hygiene is essential for preventing infections, which can lead to septic shock, but it is not directly related to preventing hypovolemic shock. While important, hand hygiene does not specifically address the fluid and blood volume issues involved in hypovolemic shock.

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Correct Answer is B

Explanation

Choice A reason:

Septic shock is caused by severe infections leading to systemic inflammation and vasodilation. Symptoms often include fever, increased heart rate, low blood pressure, and signs of infection. While the vital signs in this scenario include tachycardia and hypotension, there is no indication of infection, fever, or other signs that would suggest sepsis as the primary cause of the shock.

Choice B reason:

Hypovolemic shock results from a significant loss of blood or fluids, common in traumatic injuries. The patient's tachycardia, hypotension, and decreased pulse oximetry indicate a possible significant blood loss due to the trauma from the motor vehicle accident. These signs are typical for hypovolemic shock, making it the most likely diagnosis given the context.

Choice C reason:

Cardiogenic shock is caused by the heart's failure to pump effectively, often due to myocardial infarction or heart disease. While hypotension and tachycardia are present, there are no other indicators, such as chest pain or history of heart disease, to suggest that the patient's shock is cardiogenic in nature. The context of a traumatic accident points more towards hypovolemic shock.

Choice D reason:

Anaphylactic shock is a severe allergic reaction causing widespread vasodilation and bronchoconstriction. Symptoms include sudden hypotension, tachycardia, and difficulty breathing. There is no mention of an allergen exposure or typical allergic reactions (such as rash, itching, or swelling) in the patient's history, making anaphylactic shock an unlikely cause of the symptoms described.

A. Myocardium and brain B. Pulmonary vasculature C. Small and large bowel D. Hepatic and renal vasculature

Correct Answer is A

Explanation

Choice A reason:

In a state of shock, the body prioritizes blood flow to vital organs such as the myocardium (heart muscle) and the brain. This is because these organs are essential for survival, and their function is critical. The body's compensatory mechanisms ensure that blood is diverted to these areas to maintain their perfusion, even at the expense of less vital organs.

Choice B reason:

The pulmonary vasculature, which involves the blood vessels of the lungs, is important for gas exchange but is not specifically prioritized in the same way that the myocardium and brain are during shock. While maintaining adequate oxygenation is crucial, the body’s immediate focus is on sustaining the heart and brain.

Choice C reason:

The small and large bowel are not considered high-priority organs during shock. Blood flow to the gastrointestinal tract can be reduced to preserve perfusion to more vital organs. This reduced blood flow can result in decreased bowel activity and hypoactive bowel sounds.

Choice D reason:

While the hepatic (liver) and renal (kidneys) vasculature are important for detoxification and fluid balance, they are not prioritized over the heart and brain during shock. Reduced perfusion to these organs can lead to liver and kidney dysfunction, but the immediate priority is ensuring the survival of the heart and brain.

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The nurse is caring for a patient recovering from surgery. What action should the nurse perform to prevent the onset of hypovolemic shock?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who is the victim of a traumatic motor vehicle accident. Vital signs are: T-98.8 oral, P-140, B/P-86/52, R-28, pulse oximetry-92% on room air. The nurse would suspect which type of shock?

Correct Answer is B

Explanation

In a state of shock, the body attempts to maintain homeostasis by maintaining priority blood flow to the:

Correct Answer is A

Explanation

What is a late sign of septic shock?

Cardiac output (CO) equals:

The nurse working in the ICU is receiving a client diagnosed with late septic shock. The nurse correlates which clinical manifestations to this stage of septic shock?

What is the initial therapy of choice for the treatment of anaphylactic shock?

The nurse caring for a client in the early stages of hypovolemic shock who is hyperventilating. The nurse monitors for which acid-base imbalance based on this clinical presentation?

The nurse is caring for a patient who is the victim of a traumatic motor vehicle accident. Vital signs are: T-98.8°F oral, P-140, B/P-86/52, R-28, pulse oximetry-92% on room air. The nurse would suspect which type of shock?

During the initial stage of shock, which manifestation should the nurse monitor for when assessing the client?

Cardiogenic shock occurs when the heart's pumping ability is compromised. What can impair the pumping ability of the heart? Select all that apply.