A nurse is caring for a client who is at risk for developing shock. Which of the following findings is the earliest indicator that this complication is occurring?

Increased respiratory rate

Hypotension

Anuria

Decreased level of consciousness

Answer and Explanation

The Correct Answer is A

A. Increased respiratory rate – Tachypnea (increased respiratory rate) is often the earliest compensatory sign of shock as the body attempts to correct metabolic acidosis and hypoxia by increasing oxygen intake and carbon dioxide removal.
B. Hypotension – Occurs later in the shock progression, typically when compensatory mechanisms fail.
C. Anuria – Indicates prolonged or severe shock leading to organ failure, not an early finding.
D. Decreased level of consciousness – A later sign, suggesting impaired cerebral perfusion due to worsening shock.

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Correct Answer is D

Explanation

A. Ventricular tachycardia is less commonly triggered by suctioning.
B. Sinus tachycardia may occur but is not the most common arrhythmia during suctioning.
C. Supraventricular tachycardia is not typically associated with suctioning.
D. Sinus bradycardia is the most common arrhythmia caused by vagal stimulation during endotracheal suctioning.

A. Increase the head of the bed. B. Place the patient in a recovery position. C. Stop the infusion of the medication. D. Slow down the infusion of the medication.

Correct Answer is C

Explanation

A. Increasing the head of the bed may help ease breathing but does not address the potential cause of the problem.
B. The recovery position is used for unconscious patients to maintain an open airway—not appropriate here.
C. Stopping the infusion of the medication is the first and most critical action. The client is likely experiencing an allergic reaction or anaphylaxis to penicillin, and continuing the drug could worsen symptoms.
D. Slowing the infusion does not prevent further reaction and delays stopping the exposure to the allergen.

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A nurse is caring for a client who is at risk for developing shock. Which of the following findings is the earliest indicator that this complication is occurring?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse who is caring for a client in ICU on a ventilator assesses a need for suctioning and is aware that the most common cardiac arrhythmia occurring during endotracheal suctioning is:

Correct Answer is D

Explanation

A client is receiving an initial dose of penicillin IV. During the infusion, the client becomes short of breath. What is the first thing the nurse should do?

Correct Answer is C

Explanation

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