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 D
Explanation
Choice A rationale:
Obtaining the number of the client’s provider is not the immediate action to take. The client is showing signs of a possible stroke (right-sided weakness and slurred speech), which is a medical emergency.
Choice B rationale:
Finding a location for the client to sit is not the immediate action to take. The client needs medical attention immediately due to the signs of a possible stroke.
Choice C rationale:
Driving the client to the nearest emergency room is not the best action to take. It would be faster and safer to call emergency medical services who are trained to handle such situations.
Choice D rationale:
Calling emergency medical services is the correct action. The client is showing signs of a possible stroke, which requires immediate medical attention.
Correct Answer is C
Explanation
Choice A rationale:
Metabolic alkalosis is incorrect because it would present with a high pH and high HCO3, which is not the case here.
Choice B rationale:
Respiratory acidosis is incorrect because it would present with a low pH and high PaCO2, which is not the case here.
Choice C rationale:
Metabolic acidosis is correct because it presents with a low pH and low HCO3, which matches the client’s ABG results.
Choice D rationale:
Respiratory alkalosis is incorrect because it would present with a high pH and low PaCO2, which is not the case here.
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