A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?

Widening pulse pressure

Increased heart rate

Increased deep tendon reﬂexes

Pulse oximetry 96%

Answer and Explanation

The Correct Answer is B

Choice A Reason: This is incorrect. Widening pulse pressure is not a sign of hypovolemic shock, but rather of increased intracranial pressure or aortic regurgitation. Hypovolemic shock causes narrowing pulse pressure due to decreased stroke volume and increased peripheral resistance.

Choice B Reason: This is correct. Increased heart rate is a sign of hypovolemic shock, as the body tries to compensate for the decreased blood volume and cardiac output by increasing the heart rate and contractility.

Choice C Reason: This is incorrect. Increased deep tendon reﬂexes are not a sign of hypovolemic shock, but rather of hyperreﬂexia or tetany. Hypovolemic shock causes decreased deep tendon reﬂexes due to reduced perfusion and oxygenation of the muscles and nerves.

Choice D Reason: This is incorrect. Pulse oximetry 96% is not a sign of hypovolemic shock, but rather of normal oxygen saturation. Hypovolemic shock causes decreased pulse oximetry due to hypoxia and impaired gas exchange.

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Correct Answer is ["B","C","D","E"]

Explanation

Choice a) is incorrect because nausea is not a common manifestation of ARF. Nausea is a sensation of discomfort in the stomach that may or may not lead to vomiting. Nausea can be caused by many other conditions, such as gastroenteritis, motion sickness, or pregnancy.

Choice b) is correct because severe dyspnea is a common manifestation of ARF. Dyspnea is a subjective feeling of difficulty or discomfort in breathing. Severe dyspnea indicates that the client is not getting enough oxygen and may have low blood oxygen levels (hypoxemia) or high carbon dioxide levels (hypercapnia).

Choice c) is correct because headache is a common manifestation of ARF. Headache is a pain or discomfort in the head, scalp, or neck. Headache can be caused by high carbon dioxide levels (hypercapnia), which can affect the blood vessels and nerves in the brain.

Choice d) is correct because a decreased level of consciousness is a common manifestation of ARF. Level of consciousness is a measure of how alert and oriented a person is. A decreased level of consciousness can be caused by low blood oxygen levels (hypoxemia), high carbon dioxide levels (hypercapnia), or acid-base imbalance, which can aﬀect brain function and mental status.

Choice e) is correct because hypotension is a common manifestation of ARF. Hypotension is a condition in which the blood pressure is lower than normal. Hypotension can be caused by low blood oxygen levels (hypoxemia), which can impair heart function and reduce cardiac output.

A. Slow the rate to 50 mL/hr. B. Slow the rate to 20 mL/hr. C. Continue the rate at 125 mL/hr. D. Increase the rate to 250 mL/hr.

Correct Answer is C

Explanation

The correct answer is: C. Continue the rate at 125 mL/hr.
Choice A: Slow the rate to 50 mL/hr
Slowing the IV fluid rate to 50 mL/hr is not appropriate for a patient with a head injury. Adequate fluid management is crucial to maintain cerebral perfusion pressure and prevent secondary brain injury. Reducing the rate to 50 mL/hr could lead to hypovolemia, which might decrease cerebral perfusion and worsen the patient’s condition.
Choice B: Slow the rate to 20 mL/hr
Slowing the IV fluid rate to 20 mL/hr is even less appropriate. Such a low rate would likely result in significant hypovolemia, severely compromising cerebral perfusion pressure. This could exacerbate the patient’s head injury by reducing the blood flow to the brain, leading to further damage.
Choice C: Continue the rate at 125 mL/hr
Continuing the rate at 125 mL/hr is appropriate. This rate helps maintain euvolemia, which is essential for ensuring adequate cerebral perfusion pressure in patients with head injuries. Maintaining a stable fluid rate helps prevent both hypovolemia and hypervolemia, both of which can negatively impact intracranial pressure and cerebral perfusion.
Choice D: Increase the rate to 250 mL/hr
Increasing the IV fluid rate to 250 mL/hr is not recommended. Overhydration can lead to increased intracranial pressure, which can be detrimental to a patient with a head injury. Excessive fluid administration can cause cerebral edema, worsening the patient’s condition.

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A nurse in the emergency department is assessing a client who has internal injuries from a car crash. The client is disoriented to time and place, diaphoretic, and his lips are cyanotic. The nurse should anticipate which of the following findings as an indication of hypovolemic shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Correct Answer is C

Explanation

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