A nurse is caring for a client who is at risk for shock. Which of the following findings is the earliest indicator that this complication is developing?
Decreased level of consciousness
Increased respiratory rate
Hypotension
Anuria
The Correct Answer is B
Choice A Reason: This is incorrect because a decreased level of consciousness is a late sign of shock, not an early one. Decreased level of consciousness indicates that the brain is not receiving enough oxygen and blood flow, which can lead to irreversible damage and death.
Choice B Reason: This is correct because increased respiratory rate is an early sign of shock, indicating hypoxia. This finding indicates that the client is experiencing hypoxia, which is a lack of oxygen in the tissues and organs. Hypoxia is a common and early sign of shock, which is a condition where the body's vital organs do not receive enough blood
flow and oxygen due to low blood pressure, low cardiac output, or low blood volume. The client's respiratory rate increases as a compensatory mechanism to increase oxygen intake and delivery.
Choice C Reason: This is incorrect because hypotension is a late sign of shock, not an early one. Hypotension indicates that the blood pressure is too low to maintain adequate perfusion and oxygenation to the vital organs.
Choice D Reason: This is incorrect because anuria is a late sign of shock, not an early one. Anuria indicates that the kidneys are not receiving enough blood flow and oxygen, which can result in acute kidney injury or failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: This is incorrect. Widening pulse pressure is not a sign of hypovolemic shock, but rather of increased intracranial pressure or aortic regurgitation. Hypovolemic shock causes narrowing pulse pressure due to decreased stroke volume and increased peripheral resistance.
Choice B Reason: This is correct. Increased heart rate is a sign of hypovolemic shock, as the body tries to compensate for the decreased blood volume and cardiac output by increasing the heart rate and contractility.
Choice C Reason: This is incorrect. Increased deep tendon reflexes are not a sign of hypovolemic shock, but rather of hyperreflexia or tetany. Hypovolemic shock causes decreased deep tendon reflexes due to reduced perfusion and oxygenation of the muscles and nerves.
Choice D Reason: This is incorrect. Pulse oximetry 96% is not a sign of hypovolemic shock, but rather of normal oxygen saturation. Hypovolemic shock causes decreased pulse oximetry due to hypoxia and impaired gas exchange.
Correct Answer is B
Explanation
Choice a) is incorrect because calcium levels are not directly affected by hemodialysis. Calcium is a mineral that is important for bone health, blood clotting, and muscle contraction. Hemodialysis does not remove calcium from the blood, but it may cause low calcium levels if the dialysate fluid has a lower concentration of calcium than the blood.
Choice b) is correct because potassium levels are decreased by hemodialysis. Potassium is an electrolyte that is essential for nerve and muscle function, especially the heart. Hemodialysis removes excess potassium from the blood, which can build up in people with kidney failure and cause irregular heartbeats, muscle weakness, or even cardiac arrest.
Choice c) is incorrect because protein levels are not decreased by hemodialysis. Protein is a macromolecule that is composed of amino acids and performs various functions in the body, such as building and repairing tissues, transporting substances, and regulating processes. Hemodialysis does not remove protein from the blood, but it may cause low protein levels if the client has a poor diet or loses protein through other means, such as urine or wounds.
Choice d) is incorrect because RBC count is not decreased by hemodialysis. RBCs are red blood cells that carry oxygen throughout the body. Hemodialysis does not remove RBCs from the blood, but it may cause low RBC count if the client has anemia, which is a common complication of kidney failure. Anemia can be caused by reduced production of erythropoietin (a hormone that stimulates RBC production), iron deficiency, or blood loss.
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