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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is: C.
Choice A reason: A pH of 7.50 and HCO3 of 31 mm Hg suggest a metabolic alkalosis due to the high bicarbonate level. However, during a panic attack, hyperventilation leads to respiratory alkalosis, not metabolic, due to the excessive exhalation of CO2, which is not consistent with this option.
Choice B reason: A pH of 7.30 and HCO3 of 19 mm Hg indicate a metabolic acidosis due to the low bicarbonate level. This is not typically associated with hyperventilation during a panic attack, which usually causes respiratory alkalosis, characterized by a decrease in CO2 levels and an increase in pH.
Choice C reason: A pH of 7.47 and PaCO2 of 31 mm Hg are indicative of respiratory alkalosis, which is expected during hyperventilation as a result of a panic attack. Hyperventilation causes a decrease in carbon dioxide (PaCO2) levels, leading to an increase in pH. The normal ranges for arterial blood gases are: pH 7.35-7.45, PaCO2 35-45 mm Hg, and HCO3 22-26 mEq/L.
Choice D reason: A pH of 7.32 and PaCO2 of 50 mm Hg suggest respiratory acidosis due to the elevated PaCO2 level. This would be more consistent with hypoventilation, which is not the case during a panic attack where hyperventilation occurs.
Correct Answer is A
Explanation
Choice A rationale:
Check the client's respiratory rate and lung sounds When an IV bag is unexpectedly empty, it is important to assess the client for potential complications, especially if the client was receiving fluid therapy. Checking the respiratory rate and lung sounds is essential to ensure there are no signs of respiratory distress, such as crackles or wheezing, which could indicate fluid overload or a pulmonary issue.
Choice B rationale:
Request NPO status for the client Requesting nothing by mouth (NPO) status is not the immediate action required when an IV bag is empty. The priority is to assess the client's condition and address any potential issues first.
Choice C rationale:
Elevate the head of the bed to high Fowler's Elevating the head of the bed to high Fowler's is a measure to assist with preventing aspiration during oral intake. It is not the primary action required in this situation, where assessing the client's respiratory and fluid status is more important.
Choice D rationale:
Measure the client's temperature Measuring the client's temperature is not the immediate priority in this scenario. Assessing the client's respiratory and fluid status is more critical to identify any potential issues associated with the empty IV bag. .
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