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 C
Explanation
Answer: C
Rationale:
A) "I'm glad that I can work remotely from my computer. Prolonged use of a computer can strain the eyes, potentially interfering with the healing process after a retinal reattachment procedure. Clients are generally advised to limit screen time during recovery.
B) "I can't wait to be able to take a bath. Submerging the face in water, as during a bath, is discouraged postoperatively due to the risk of introducing bacteria into the eye and delaying healing. Clients are advised to stick to showers and avoid getting the affected eye wet.
C) "I get bored only being able to watch television. Watching television is usually permissible following retinal surgery, as it does not strain the eye excessively. This statement aligns with typical postoperative instructions.
D) "I will be relieved once I can drive myself to the store." Driving is contraindicated during the recovery phase due to potential visual disturbances and the need for the eye to heal properly. Clients are typically instructed to avoid driving until cleared by their ophthalmologist.
Correct Answer is ["A","C","D","E"]
Explanation
A. Intermittent pneumatic compression pumps: Intermittent pneumatic compression pumps can help improve circulation in the lower extremities by assisting with venous return. These devices inflate and deflate sequentially, promoting venous blood flow and reducing edema in clients with peripheral venous disease.
B. Ankle-brachial index test: The ankle-brachial index (ABI) test is a non-invasive vascular study used to assess peripheral arterial disease (PAD). It compares the blood pressure in the ankle with the blood pressure in the arm to evaluate arterial circulation.
C. Layered wraps: Layered wraps, such as compression bandages or stockings, are typically used in the management of venous insufficiency and venous ulcers. They are not as commonly utilized in peripheral venous disease, however, they may be beneficial for some clients with PVD.
D. Elevation of legs: Elevating the legs above the level of the heart can help reduce edema and improve venous return in clients with peripheral venous disease. Gravity assists in draining blood from the lower extremities back toward the heart, thereby reducing swelling and discomfort.
E. Exercise: Regular physical activity, particularly lower extremity exercises such as walking, can promote venous return and improve circulation in clients with peripheral venous disease. Exercise helps to pump blood back to the heart, reducing venous stasis and the risk of complications such as venous thrombosis.
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