A nurse assisting in the collection of data for a client who is in the early compensatory stage of hypovolemic shock.
Which of the following findings should the nurse expect?
Tachycardia.
Diminished urine output.
Cold clammy skin.
Unconsciousness.
The Correct Answer is A
Choice A rationale:
Tachycardia, or a rapid heart rate, is a common early sign of hypovolemic shock as the body tries to compensate for the decreased blood volume by increasing the heart rate.
Choice B rationale:
Diminished urine output is a sign of hypovolemic shock, but it is not typically an early sign.
Choice C rationale:
Cold, clammy skin is a sign of hypovolemic shock, but it is not typically an early sign.
Choice D rationale:
Unconsciousness is a late sign of hypovolemic shock, indicating severe blood loss and inadequate perfusion to the brain.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Repeating the potassium level is not the first action to take. The nurse already has a recent lab value.
Choice B rationale:
The nurse should withhold the medication. The normal range for potassium is 3.5-5.0 mEq/L. A level of 5.5 mEq/L is high, so giving more potassium could lead to hyperkalemia.
Choice C rationale:
Monitoring for paresthesia is important in hyperkalemia, but it is not the first action. The nurse should first prevent further increase in potassium levels.
Choice D rationale:
Administering a hypertonic solution is not relevant in this situation. It does not directly address the high potassium level.
Correct Answer is C
Explanation
Choice A rationale:
An angle of 60° is not typically used for IM injections. It is more commonly used for subcutaneous injections.
Choice B rationale:
An angle of 45° is also more commonly used for subcutaneous injections, not IM injections.
Choice C rationale:
An angle of 90° is the correct angle for an IM injection into the ventrogluteal muscle. This allows for the needle to penetrate deep into the muscle tissue.
Choice D rationale:
An angle of 75° is not typically used for any type of injection. It could potentially cause injury to the client if used for an IM injection.
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