A nurse is measuring the vital signs of a client he suspects has hypovolemic shock.
Which of the following findings should the nurse expect?

Low BP and high pulse rate.

Low BP and low pulse rate.

High BP and high pulse rate.

High BP and low pulse rate.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Hypovolemic shock is characterized by a decrease in blood volume, leading to low blood pressure and compensatory mechanisms such as a high pulse rate. When the body experiences a significant loss of blood or fluid, it attempts to maintain perfusion to vital organs by increasing the heart rate to ensure an adequate blood supply. Low blood pressure and a high pulse rate are classic signs of hypovolemic shock.

Choice B rationale:

A low BP and low pulse rate are not indicative of hypovolemic shock. Hypovolemic shock is associated with a rapid and weak pulse rate as the body tries to compensate for decreased blood volume. A low pulse rate could suggest other conditions, such as bradycardia, rather than hypovolemic shock.

Choice C rationale:

High BP and high pulse rate are not typical findings in hypovolemic shock. Hypovolemic shock is characterized by low blood pressure and a high pulse rate as the body attempts to compensate for the reduced blood volume. High blood pressure is more commonly associated with conditions like hypertension, not hypovolemic shock.

Choice D rationale:

High BP and low pulse rate are not consistent with the characteristics of hypovolemic shock. As mentioned earlier, hypovolemic shock is marked by low blood pressure and a high pulse rate due to the body's efforts to maintain adequate perfusion. High blood pressure and a low pulse rate may suggest other medical conditions unrelated to hypovolemic shock.

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Correct Answer is D

Explanation

Choice A rationale:

Having the client cough and expectorate secretions is a reasonable intervention for managing respiratory distress, but it is not the top priority. The nurse should first assess the client's overall respiratory status to determine the severity of the problem.

Choice B rationale:

Instructing the client to use a pursed-lip breathing technique is a helpful strategy to improve breathing in some cases. However, it should not be the top priority when a client is experiencing difficulty breathing. Assessment should come first.

Choice C rationale:

Increasing the oxygen flow to 3 L/min without a proper assessment is not advisable. It's essential to evaluate the client's respiratory status before making any adjustments to the oxygen therapy.

Choice D rationale:

"Evaluate the client's respiratory status" is the correct response. When a client with COPD and oxygen therapy reports difficulty breathing, the nurse's priority is to assess the client's respiratory status. This assessment will help determine the cause of the breathing difficulty and guide appropriate interventions. The nurse should also check the oxygen saturation levels, respiratory rate, and auscultate lung sounds to assess the severity of the issue.

A. "I will wear stockings with elastic tops.”. B. "I will avoid crossing my legs at the knees.”. C. "I will not go barefoot.”. D. "I will use a thermometer to check the temperature of my bath water.”. .

Correct Answer is A

Explanation

The correct answer is Choice A: "I will wear stockings with elastic tops."

Choice A rationale:

Wearing stockings with elastic tops can constrict blood flow in the legs, which is counterproductive for individuals with peripheral vascular disease. Compression stockings specifically designed for PVD are recommended, but these should be properly fitted and used according to medical advice.

Choice B rationale:

Avoiding crossing the legs at the knees is appropriate for individuals with PVD, as this can impede blood flow and worsen symptoms.

Choice C rationale:

Not going barefoot is important for clients with PVD, as it reduces the risk of injury and infection, which can be more serious due to compromised circulation.

Choice D rationale:

Using a thermometer to check the temperature of bath water is crucial for clients with PVD to avoid burns, since they may have decreased sensation in their extremities.

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A nurse is measuring the vital signs of a client he suspects has hypovolemic shock.Which of the following findings should the nurse expect?

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A nurse is measuring the vital signs of a client he suspects has hypovolemic shock.
Which of the following findings should the nurse expect?