A nurse is caring for a client who is experiencing pooling of blood in the periphery. Which of the following occurs in a client with distributive shock?

Increased mean arterial pressure (MAP)

Decreased venous return

Decreased heart rate

Increased cardiac output

Answer and Explanation

The Correct Answer is B

A. Distributive shock is associated with decreased MAP, not increased.
B. Decreased venous return occurs in distributive shock due to the pooling of blood in the periphery, leading to reduced preload and decreased cardiac output.
C. Distributive shock typically results in increased heart rate as the body attempts to compensate for decreased blood pressure and venous return.
D. Cardiac output is generally decreased in distributive shock due to reduced venous return and impaired blood flow.

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Correct Answer is B

Explanation

A. Assessing for sources of bleeding is important in clients with neutropenia, but the highest priority is preventing infection, as the client’s absolute neutrophil count is zero, indicating an extremely high risk for infection.
B. Limiting contact with infected visitors and placing the client in positive pressure isolation is crucial for preventing infections. With a neutrophil count of zero, the client is highly immunocompromised and at a significant risk of infection, making this the highest priority action.
C. Administering antiemetics and assessing nutrition and hydration are important for managing symptoms, but they do not address the immediate risk of infection associated with severe neutropenia.
D. Monitoring energy levels and implementing energy-conserving techniques are important for overall care but do not address the urgent need to protect the client from infections due to their neutropenic status.

A. Wear a face shield. B. Wear clean gloves. C. Wear sterile gloves. D. Wear an N95 respirator mask.

Correct Answer is B

Explanation

A. A face shield is necessary when there is a risk of splashes, but not required for simply checking a pulse.
B. Clean gloves are appropriate for contact with the client or the wound, as MRSA is transmitted through direct contact. This prevents contamination while assessing the client.
C. Sterile gloves are not required for checking a pulse unless performing a sterile procedure.
D. An N95 respirator mask is used for airborne precautions, not necessary for MRSA, which is contact-transmitted.

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A nurse is caring for a client who is experiencing pooling of blood in the periphery. Which of the following occurs in a client with distributive shock?

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