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 C
Explanation
A. Question-and-answer: This strategy involves the nurse asking questions to assess the client's understanding and provide information, but it does not involve the client performing the skill.
B. Role-play: Role-play involves the client acting out scenarios to practice skills, but this is not the method being described where the client is simply asked to perform a skill.
C. Return demonstration: This strategy involves the client performing a skill or procedure after being shown how to do it, allowing the nurse to assess the client's competence in the skill. This is the method being described in the scenario.
D. Discussion: Discussion involves talking through concepts or information but does not include the client actively performing a skill.
Correct Answer is B
Explanation
A. A JP drain is not used for medication administration; its purpose is to remove fluid from the wound area.
B. The primary purpose of a JP drain is to prevent fluid from accumulating in the wound, which helps reduce the risk of infection and promotes healing by allowing continuous drainage of postoperative fluids.
C. While a JP drain helps manage fluid accumulation, it does not eliminate the need for wound irrigations if prescribed as part of the care plan.
D. A JP drain helps manage excess fluid but is not specifically designed to limit bleeding from the surgical site. Bleeding control is generally managed through other measures and monitoring.
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