A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Hypertension

Bradypnea

Oliguria

Flushing of the skin

Answer and Explanation

The Correct Answer is C

Choice A Reason: This is incorrect because hypertension is a condition of high blood pressure. A client who has hypovolemic shock is more likely to have hypotension, which is a condition of low blood pressure, due to ﬂuid loss and reduced cardiac output.

Choice B Reason: This is incorrect because bradypnea is a condition of slow breathing. A client who has hypovolemic shock is more likely to have tachypnea, which is a condition of fast breathing, due to hypoxia and increased respiratory demand.

Choice C Reason: This is correct because oliguria is a condition of low urine output. A client who has hypovolemic shock may have oliguria due to decreased renal perfusion and activation of the renin-angiotensin-aldosterone system, which causes sodium and water retention.

Choice D reason: This is incorrect because ﬂushing of the skin is a condition of redness and warmth of the skin. A client who has hypovolemic shock may have pallor and coolness of the skin due to vasoconstriction and reduced blood ﬂow.

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Correct Answer is A

Explanation

The correct answer is a. Respiratory status.

Choice A: Respiratory Status

Reason: After the evacuation of a subdural hematoma, monitoring the respiratory status is crucial. This is because changes in respiratory patterns can indicate increased intracranial pressure (ICP) or brainstem compression, which are life-threatening conditions. Ensuring that the airway is clear and that the patient is breathing adequately is the top priority. Normal respiratory rate for adults is 12-20 breaths per minute.

Choice B: Temperature

Reason: While monitoring temperature is important to detect infections or other complications, it is not the immediate priority in the acute postoperative period following a subdural hematoma evacuation. Fever can indicate infection, but it is less likely to cause immediate life-threatening complications compared to respiratory issues.

Choice C: Intracranial Pressure

Reason: Monitoring intracranial pressure (ICP) is very important in patients with brain injuries. Normal ICP ranges from 5-15 mmHg. However, changes in respiratory status can be an early indicator of increased ICP. Therefore, while ICP monitoring is critical, ensuring the patient’s respiratory status is stable takes precedence.

Choice D: Serum Electrolytes

Reason: Serum electrolytes are important to monitor for overall metabolic stability and to detect imbalances that could affect neurological function. Normal ranges for key electrolytes are: Sodium (135-145 mEq/L), Potassium (3.5-4.5 mEq/L), and Chloride (80-100 mEq/L). However, these are not the immediate priority in the acute phase following surgery compared to respiratory status.

A. Hypomagnesemia B. Hyperkalemia C. Decreased creatinine level D. Increased glomerular filtration rate (GFR)

Correct Answer is B

Explanation

Choice A Reason: This choice is incorrect because hypomagnesemia is not a common finding in the oliguric phase of acute kidney injury. Hypomagnesemia is a condition in which the serum magnesium level is lower than normal (less than 1.5 mEq/L). It may be caused by various factors such as malnutrition, diarrhea, diuretics, or alcohol abuse. It may cause symptoms such as muscle weakness, tremors, tetany, or cardiac arrhythmias.

Choice B Reason: This choice is correct because hyperkalemia is a common finding in the oliguric phase of acute kidney injury. Hyperkalemia is a condition in which the serum potassium level is higher than normal (more than 5 mEq/L). It may be caused by reduced renal excretion of potassium due to decreased urine output (oliguria). It may cause symptoms such as muscle weakness, paresthesia, bradycardia, or cardiac arrest.

Choice C Reason: This choice is incorrect because decreased creatinine level is not a common finding in the oliguric phase of acute kidney injury. Creatinine is a waste product of muscle metabolism that is filtered by the kidneys and excreted in urine. A normal creatinine level ranges from 0.6 to 1.2 mg/dL for men and 0.5 to 1.1 mg/dL for women. In acute kidney injury, creatinine level usually increases due to reduced renal function and impaired clearance of creatinine.

Choice D Reason: This choice is incorrect because increased glomerular filtration rate (GFR) is not a common finding in the oliguric phase of acute kidney injury. GFR is a measure of how well

the kidneys filter blood and remove waste products.

A normal GFR range is 90,to 120 mL/min/1.73 m2. In acute kidney injury, GFR usually decreases due to reduced blood ﬂow,to,the kidneys or damage to the glomeruli, which are the tiny blood vessels that filter blood in the kidneys.

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A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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