A nurse is providing care for a postoperative client. Which of the following manifestations should the nurse identify as indicating the development of postoperative shock?
The client has metabolic alkalosis and warm extremities
The client develops bradycardia and bradypnea
The client has hypotension and is confused
The client has hypertension and anuria
The Correct Answer is C
A. The client has metabolic alkalosis and warm extremities: Metabolic alkalosis and warm extremities are not typically indicative of postoperative shock. Metabolic alkalosis may be caused by excessive vomiting or prolonged gastric suctioning, but it is not a hallmark sign of shock. Warm extremities may suggest adequate peripheral perfusion rather than impaired perfusion seen in shock.
B. The client develops bradycardia and bradypnea: Bradycardia (slow heart rate) and bradypnea (slow respiratory rate) may occur as compensatory mechanisms in certain types of shock, such as neurogenic shock. However, they are not specific indicators of postoperative shock. Tachycardia (rapid heart rate) and tachypnea (rapid respiratory rate) are more common findings in most types of shock, including postoperative shock.
C. The client has hypotension and is confused: Hypotension (low blood pressure) and confusion are classic signs of shock, including postoperative shock. Hypotension indicates inadequate perfusion of vital organs, while confusion may result from cerebral hypoperfusion. Altered mental status, such as confusion, is a significant neurological manifestation of shock.
D. The client has hypertension and anuria: Hypertension (high blood pressure) and anuria (decreased urine output) are not typical manifestations of postoperative shock. Hypertension may occur in certain conditions that can lead to shock, such as septic shock, during the compensatory phase. However, it is not a primary sign of shock. Anuria may occur in cases of severe hypovolemic shock but is not specific to postoperative shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. In the community, the nurse should notify emergency services: In a community setting, such as outside the hospital or in a public area, it is essential to activate emergency medical services (EMS) by calling for help immediately when initiating CPR.
B. Compression rates and depths vary depending on the setting: Compression rates and depths for CPR follow standardized guidelines set by organizations such as the American Heart Association (AHA) and may not significantly differ between community and hospital settings. These guidelines typically recommend a compression rate of 100-120 compressions per minute and a compression depth of at least 2 inches (5 centimeters) for adults.
C. In the hospital, codes are addressed by an interprofessional team: In a hospital setting, cardiac arrest situations are typically addressed by an interprofessional team consisting of physicians, nurses, respiratory therapists, and other healthcare providers. This team-based approach allows for coordinated efforts in resuscitation, including advanced interventions such as airway management, medications, and defibrillation.
D. In the community, the nurse might use laypeople for assistance: In a community setting, especially if the nurse is providing CPR outside of a healthcare facility, there may be a need to involve laypeople or bystanders for assistance. Promptly recruiting bystanders to call for help, retrieve an AED if available, or assist with chest compressions can improve outcomes for the victim of cardiac arrest.
E. In the community, the use of automated external defibrillators (AEDs) requires the presence of a health care provider: In many community settings, including public places like shopping malls, airports, and schools, automated external defibrillators (AEDs) are available for use by laypeople or bystanders. While the presence of a healthcare provider is beneficial, AEDs are designed to provide audio and visual instructions for use by individuals without medical training, allowing for rapid defibrillation in cases of sudden cardiac arrest.
Correct Answer is B
Explanation
A. Septal myectomy: Septal myectomy is a surgical procedure primarily used to treat hypertrophic cardiomyopathy (HCM), not atrial fibrillation. It involves removing a portion of the thickened septal wall in the heart to improve blood flow.
B. Synchronized electrical cardioversion: Synchronized electrical cardioversion is a procedure used to convert abnormal heart rhythms, such as atrial fibrillation, back to normal sinus rhythm. It involves delivering a synchronized electrical shock to the heart at a specific point in the cardiac cycle to restore normal rhythm.
C. Pericardiocentesis: Pericardiocentesis is a procedure used to remove fluid from the pericardial sac surrounding the heart. It is typically performed to relieve cardiac tamponade or to investigate the cause of pericardial effusion.
D. Pericardial window: A pericardial window is a surgical procedure performed to create a permanent opening in the pericardium, the sac surrounding the heart. It is usually done to drain fluid or air from the pericardial space, often in cases of recurrent pericardial effusion or cardiac tamponade.
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