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 D

Explanation

Choice A Reason: This choice is incorrect because ﬂatened neck veins are not a sign of cardiac tamponade. Cardiac tamponade is a condition in which ﬂuid accumulates in the pericardial sac that surrounds the heart, causing compression and impaired filling of the heart chambers. This leads to reduced cardiac output and hypotension. One of the manifestations of cardiac tamponade is distended neck veins due to increased venous pressure and impaired venous return.

Choice B Reason: This choice is incorrect because bradycardia is not a sign of cardiac tamponade. Bradycardia is a condition in which the heart rate is slower than normal (less than 60 beats per minute). It may be caused by various factors such as vagal stimulation, medication side eﬀects, hypothyroidism, or sinus node dysfunction. It may cause symptoms such as fatigue, dizziness, or syncope, but it does not indicate cardiac tamponade.

Choice C Reason: This choice is incorrect because sudden lethargy is not a specific sign of cardiac tamponade. Lethargy is a condition in which the person feels tired, sluggish, or drowsy. It may be caused by various factors such as sleep deprivation, depression, infection, anemia, or hypoglycemia. It may aﬀect the person's mental and physical performance, but it does not indicate cardiac tamponade.

Choice D Reason: This choice is correct because muﬄed heart sounds are a sign of cardiac tamponade. Muﬄed heart sounds are heart sounds that are fainter or softer than normal due to reduced transmission of sound waves through ﬂuid-filled pericardial sac. They may indicate that the heart function is compromised by cardiac tamponade and require immediate intervention such as pericardiocentesis (removal of ﬂuid from pericardial sac).

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?

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