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).
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Airway obstruction is the priority because burns to the head, neck, and chest can compromise the airway due to swelling, soot, and edema. Immediate assessment and intervention are critical to ensure the airway remains patent and to prevent respiratory distress.
B. While infection is a significant risk in burn patients, addressing airway concerns takes precedence to prevent immediate life-threatening complications.
C. Paralytic ileus is a concern in burn patients but is less immediate compared to the risk of airway obstruction.
D. Fluid imbalance is crucial in burn management, but ensuring a clear airway is the immediate priority to prevent severe complications such as asphyxia.
Correct Answer is D
Explanation
A. While monitoring for side effects of immunosuppressants is important, the immediate priority is managing the risk associated with the primary condition.
B. Constipation is a common issue but is not the primary concern in the context of ITP.
C. Fatigue may be related to anemia or other factors but is secondary to the risk of bleeding in ITP.
D. Bleeding is the priority concern in ITP due to the low platelet count, which increases the risk of hemorrhage and requires careful monitoring and intervention.
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