A nurse is assessing a client who has experienced significant blood loss. Which of the following is a clinical sign of hypovolemia?

Bradycardia

Hypertension

Polyuria

Cool, clammy skin

Answer and Explanation

The Correct Answer is D

A. Bradycardia is not typical in hypovolemia; tachycardia is more common as the body compensates for fluid loss.
B. Hypotension, rather than hypertension, occurs due to reduced blood volume.
C. Polyuria is not a feature of hypovolemia; decreased urine output is expected.
D. Cool, clammy skin is a classic sign of hypovolemic shock as blood flow to the skin decreases in response to blood loss.

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Correct Answer is A

Explanation

A. Respiratory acidosis occurs due to hypoventilation, which causes an accumulation of carbon dioxide in the blood, leading to increased acidity. Shallow respirations at a rate of 8 breaths per minute indicate hypoventilation, putting the client at risk for respiratory acidosis.
B. Metabolic acidosis is typically caused by metabolic issues such as kidney failure or diabetic ketoacidosis, not by respiratory changes.
C. Respiratory alkalosis results from hyperventilation, which leads to a decrease in carbon dioxide levels, causing alkalinity in the blood.
D. Metabolic alkalosis is caused by factors such as prolonged vomiting or diuretic use, not by hypoventilation.

Correct Answer is []

Explanation

Condition Most Likely Experiencing:

Type 1 diabetes

Actions to Take:

Teach the client about the signs of hyperglycemia.
Assess the client’s feet for sensation.

Parameters to Monitor:

Fingerstick blood glucose
Blood pressure

Rationale: The client has a high HbA1c (8.4%) and elevated blood glucose level (235 mg/dL), indicating poor blood glucose control. Symptoms such as fatigue, blurred vision, and dizziness suggest hyperglycemia, which can occur in clients with diabetes who have not been able to maintain regular glucose monitoring or insulin administration due to financial constraints. Teaching the client about hyperglycemia symptoms and checking feet for sensation is important due to the risk of complications like neuropathy. Monitoring blood glucose and blood pressure is essential for evaluating diabetes management and preventing complications.

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A nurse is assessing a client who has experienced significant blood loss. Which of the following is a clinical sign of hypovolemia?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is postoperative and whose respirations are shallow and 8/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?

Correct Answer is A

Explanation

Correct Answer is []

Explanation

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