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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Mitral valve prolapse often requires no treatment or is managed with medications; balloon valvuloplasty is not typically used.
B. Aortic regurgitation usually requires surgical valve replacement rather than valvuloplasty.
C. Mitral regurgitation involves backward blood flow and is generally treated with valve repair or replacement, not balloon valvuloplasty.
D. Mitral stenosis is most commonly treated with balloon valvuloplasty, especially in clients with rheumatic heart disease. This procedure helps open a narrowed mitral valve by inflating a balloon within the valve to improve blood flow.
Correct Answer is A
Explanation
A. PVCs during suctioning may indicate hypoxia or irritation; the priority is to stop suctioning and ventilate the patient with 100% oxygen to prevent worsening arrhythmias.
B. Medications may be needed later, but immediate action is oxygenation and stopping suctioning.
C. Adjusting suction pressure is important but secondary to ensuring patient oxygenation.
D. Documentation is necessary but not the priority when PVCs are noted.
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