A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?
Heart rate 180/min
Motled skin
Hypokalemia
Blood pressure 115/68 mm Hg
The Correct Answer is D
The correct answer is D. Blood pressure 115/68 mm Hg.
Choice A reason: Heart rate 180/min is incorrect because, although an increased heart rate is a compensatory mechanism, a rate of 180/min is excessively high and suggests a more severe stage of shock or other cardiac issues.
Choice B reason: Mottled skin is incorrect as it indicates poor perfusion seen in decompensated shock, where organ dysfunction begins to manifest, not in the compensatory stage.
Choice C reason: Hypokalemia, or low potassium levels, is incorrect because electrolyte imbalances are not typically a finding in the compensatory stage of shock. Normal potassium levels range from 3.5 to 5.0 mEq/L.
Choice D reason: Blood pressure 115/68 mm Hg is correct because it falls within the normal blood pressure range, which the body strives to maintain during the compensatory stage of shock through various mechanisms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Vesicles on the skin are not typical of inhalation anthrax; instead, they are more associated with cutaneous anthrax, which presents as papules that progress to vesicles and then black eschars.
Choice B reason: Respiratory failure can occur later in the course of inhalation anthrax, but it is not an early finding. It usually develops after the initial phase of nonspecific symptoms when the illness progresses to severe respiratory distress and shock.
Choice C reason: Sloughing of skin is not characteristic of inhalation anthrax. Similar to vesicles, skin sloughing may be associated with severe cutaneous infections or other dermatologic conditions, not the respiratory form of anthrax.
Choice D reason: Flu-like symptoms, such as fever, cough, malaise, muscle aches, and mild chest discomfort, are the initial and most indicative early findings of inhalation anthrax. These nonspecific symptoms often appear within several days after exposure before progressing to severe respiratory compromise.
Correct Answer is C
Explanation
Choice A: Removing the elastic bandages is not recommended. These bandages help slow the spread of venom by compressing the lymphatic vessels. Removing them could worsen the envenomation.
Choice B: This is incorrect. The nurse should not discharge the client, as they may develop serious complications from the snake bite, such as swelling, bleeding, infection, or shock. The client should be monitored closely and treated accordingly.
Choice C: This is the correct action. Antivenom treatment is crucial for serious snake envenomation. The sooner it can be administered, the better the outcome.
Choice D: While pain management is important, it is not the priority in this situation. Antivenom takes precedence over pain medication.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today