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. Taking a diuretic before sleep can lead to nocturia (frequent urination at night), disrupting sleep. Also, fluid intake may need to be restricted, not encouraged.
B. Clients with heart failure are usually advised to limit sodium to 2 grams or less per day, not 4 grams, to help reduce fluid retention.
C. Naproxen (a NSAID) is not recommended for clients with heart failure as it can cause fluid retention and worsen the condition.
D. Slowing down when tired after exercise shows an understanding of energy conservation and pacing—appropriate for managing heart failure symptoms. This indicates that teaching was effective.

A. Sick sinus syndrome B. Normal sinus rhythm C. Sinus bradycardia D. First degree heart block

Correct Answer is B

Explanation

A. Sick sinus syndrome – This involves an abnormal SA node function, often with varying rhythm disturbances (e.g., sinus pauses, bradycardia-tachycardia). The strip described is regular and does not reflect these changes.
B. Normal sinus rhythm – The rhythm is regular, the PR interval is within normal limits (0.12–0.20 seconds), the heart rate is 60 beats/min (within the normal range of 60–100), and P waves precede each QRS complex consistently.
C. Sinus bradycardia – Although the rate is 60, which is at the low end of normal, it is not below 60. Bradycardia is defined as <60 bpm.
D. First-degree heart block – First-degree AV block is characterized by a prolonged PR interval >0.20 seconds. The PR interval here is 0.16 seconds, which is normal.

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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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