A nurse is caring for a client with hypovolemic shock due to hemorrhage. Which intervention should the nurse prioritize during the initial resuscitation phase?
Administering intravenous (IV) fluids rapidly.
Administering supplemental oxygen.
Monitoring the client's blood glucose levels.
Performing neurological assessments.
The Correct Answer is A
A) Correct. The priority during the initial resuscitation phase of hypovolemic shock is to replace lost intravascular volume promptly. Administering IV fluids rapidly is crucial to improve tissue perfusion and blood pressure.
B) Incorrect. While administering supplemental oxygen is important for tissue oxygenation, it is not the primary intervention during the initial resuscitation phase.
C) Incorrect. Monitoring blood glucose levels is important for overall assessment but is not the priority during the initial resuscitation phase of hypovolemic shock.
D) Incorrect. Neurological assessments are essential but may not be the immediate priority during the initial resuscitation phase of hypovolemic shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Incorrect. Hemoglobin levels may initially be normal or slightly decreased, but they would decrease later due to the body's compensatory response to dilute the remaining blood.
B) Incorrect. Platelet count may not be significantly affected in the early stages of hemorrhage. It is mainly responsible for clot formation, which becomes more relevant in the later stages.
C) Incorrect. In the early stages of hemorrhage, the white blood cell count is not significantly affected. It plays a role in fighting infection and inflammation.
D) Correct. Hematocrit levels represent the proportion of red blood cells in the blood. During early stages of hemorrhage, there is a loss of red blood cells, leading to decreased hematocrit levels.
Correct Answer is D
Explanation
A) Incorrect. While the respiratory rate is an important vital sign to monitor, it does not directly indicate the effectiveness of a blood transfusion.
B) Incorrect. Blood pressure is a critical vital sign, but it is not specific to assessing the effectiveness of a blood transfusion.
C) Incorrect. Urinary output is essential for assessing kidney function and fluid balance, but it does not directly reflect the impact of a blood transfusion.
D) Correct. Monitoring the hemoglobin level is crucial to determine if the blood transfusion has been effective in increasing the client's red blood cell count and improving oxygen-carrying capacity.
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