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.

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Correct Answer is A

Explanation

A. Cardiac enzyme tests, such as troponin and creatine kinase-MB, are used to assess the extent of myocardial damage. Elevated levels of these enzymes indicate that heart muscle cells have been injured or have died.
B. Cardiac enzymes do not localize the MI; imaging studies like echocardiography or coronary angiography are required to identify the specific location of myocardial damage.
C. Pulmonary congestion is assessed using chest X-rays or clinical symptoms, not through cardiac enzyme levels.
D. Cardiac enzyme tests do not provide information about the structure or mobility of heart valves. This information is obtained through echocardiography or other imaging techniques.

A. Check the client's perianal skin integrity. B. Investigate the client's emotional concerns. C. Review the client's electrolyte values. D. Obtain a dietary history from the client.

Correct Answer is C

Explanation

A. While assessing perianal skin integrity is important for managing ulcerative colitis, it is not the immediate priority. Addressing electrolyte imbalances is crucial for stabilizing the client's condition first.

B. Emotional concerns are important but are secondary to addressing immediate physical health needs, such as electrolyte imbalances, which can be life-threatening if not managed promptly.

C. Reviewing electrolyte values is critical in an acute exacerbation of ulcerative colitis because diarrhea and fluid loss can lead to significant electrolyte imbalances, which need to be corrected to prevent complications.

D. Obtaining a dietary history is relevant for overall management but is not the immediate priority. Addressing electrolyte imbalances and hydration status is more urgent in acute exacerbations.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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