A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Decrease in the urinary output from 50 mL to 30 mL per hour.

Increase in the heart rate from 88 to 110/min.

Decrease in the respiratory rate from 20 to 16/min.

Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).

Answer and Explanation

The Correct Answer is B

A. A decrease in urinary output can be a sign of decreased blood volume but is less immediate than changes in heart rate.
B. An increase in the heart rate is a common compensatory response to hypovolemia as the body attempts to maintain adequate perfusion to vital organs.
C. A decrease in the respiratory rate is not typically associated with hypovolemic shock; rather, respiratory rate may increase due to compensatory mechanisms.
D. An increase in temperature is not a specific indicator of hypovolemic shock; it could be related to infection or inflammation rather than immediate hypovolemia.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. An urge to void despite an indwelling catheter may be a normal postoperative sensation due to bladder irritation, but it is not a clear indication of a complication.
B. Output of burgundy colored urine can indicate significant bleeding or a complication such as hemorrhage, which requires immediate attention.
C. A pulse rate of 88/min is within normal limits and does not suggest a postoperative complication.
D. An oral temperature of 38.2° C (100.76° F) is slightly elevated but not uncommon immediately after surgery; it may be monitored but does not immediately indicate a serious complication.

A. Apply petroleum jelly to the client's lips after oral care. B. Use a stiff toothbrush to clean the client's teeth. C. Use the thumb and index finger to keep the client's mouth open. D. Turn the client on his side before starting oral care.

Correct Answer is D

Explanation

A. Applying petroleum jelly to the client's lips can lead to aspiration if the client is unable to swallow properly. It is not recommended as a routine practice for oral care.

B. A stiff toothbrush can cause gum damage or discomfort. A soft toothbrush is preferred for oral care, especially for clients who may have sensitive or fragile gums.

C. Using the thumb and index finger to keep the client's mouth open is not safe or effective. It can cause discomfort or injury. Using appropriate tools, like a mouth prop or suction if necessary, is recommended.

D. Turning the client on their side before starting oral care is the correct action. This position helps prevent aspiration of secretions or water during oral care, reducing the risk of choking or aspiration pneumonia.

View Question and Answer

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

A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 2 hr postoperative following a transurethral resection of the prostate (TURP) gland. Which of the following assessments should the nurse view to be an indication of a postoperative complication?

Correct Answer is B

Explanation

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values?

A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect?

nurse is caring for the client who has Ménière's disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

A nurse is caring for a client who is receiving a unit of packed red blood cells. Fifteen minutes following the start of the transfusion, the nurse notes that the client is febrile, with chills and red-tinged urine. Which of the following transfusion reactions should the nurse suspect?

A nurse is teaching a client how to walk using a walker. After showing the client the procedure, the nurse asks the client to perform the skill. Which of the following types of teaching strategies is the nurse utilizing?