A patient with new third-degree burns over 60% of the body is confused and presents with a blood pressure of 79/56 mm Hg, heart rate of 132 beats/min, and respirations of 28 breaths/min with crackles on auscultation.
The patient’s body temperature is 76° F, and the skin is pale and clammy. Which stage of shock is this patient experiencing?

Irreversible.

End-organ dysfunction.

Early reversible.

Preshock.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Irreversible shock is the final stage of shock, where the body's compensatory mechanisms have failed, and damage to vital organs is irreversible. This stage is characterized by:

Profound hypotension (systolic blood pressure persistently below 60 mmHg) Severely altered mental status (unresponsiveness or coma)

Widespread organ failure (kidney failure, liver failure, respiratory failure) Lack of response to aggressive fluid resuscitation and vasopressor therapy

The patient in the question does not exhibit all of these signs and symptoms, particularly the profound hypotension and irreversible organ failure. Therefore, irreversible shock is not the most likely stage.

Choice B rationale:

End-organ dysfunction is a stage of shock where inadequate tissue perfusion has begun to cause damage to vital organs. This stage is characterized by:

Hypotension that may respond to fluid resuscitation

Signs of organ dysfunction, such as decreased urine output, altered mental status, or respiratory distress

The patient in the question does have some signs of organ dysfunction, such as confusion and crackles on lung auscultation. However, the hypotension is not as severe as typically seen in end-organ dysfunction shock, and there is no mention of other organ dysfunction like decreased urine output. Therefore, end-organ dysfunction is not the most likely stage.

Choice C rationale:

Early reversible shock is the initial stage of shock, where the body's compensatory mechanisms are still able to maintain blood pressure and organ perfusion. This stage is characterized by:

Mild to moderate hypotension Tachycardia

Cool, clammy skin Narrowed pulse pressure Restlessness or anxiety

The patient in the question presents with all of these signs and symptoms, making early reversible shock the most likely stage.

Choice D rationale:

Preshock is a state of impending shock, where the body's compensatory mechanisms are activated but not yet fully effective. This stage is characterized by:

Normal or slightly low blood pressure Tachycardia

Cool, clammy skin Restlessness or anxiety

The patient in the question has hypotension, which is not consistent with preshock. Therefore, preshock is not the correct stage.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice B rationale:

Checking the patency of the tubing is the first and most crucial step in addressing the lack of urinary output in this patient. Here's a detailed explanation of why this is the priority action:

Addresses the Most Likely Cause: Obstruction of the urinary catheter tubing is the most common and easily reversible cause of sudden cessation of urinary output in a patient with a continuous bladder irrigation system.

Prevents Complications: A blocked catheter can lead to a number of serious complications, including: Bladder distention, which can cause pain, discomfort, and potential bladder damage.

Urinary retention, which can increase the risk of urinary tract infections (UTIs) and kidney damage. Hematuria, or blood in the urine, due to clot formation in the bladder or catheter.

Non-Invasive Intervention: Checking the tubing is a simple, non-invasive procedure that can quickly identify and resolve the issue without requiring further interventions or delays in care.

Prioritizes Patient Safety: It's essential to promptly address any potential urinary obstruction to prevent the aforementioned complications and ensure patient safety.

Rationale for Other Choices:

Choice A: Administering a prescribed analgesic:

While pain management is important, it does not directly address the lack of urinary output. Pain medication would be appropriate if pain were assessed to be the cause of the decreased output, but it's not the first priority in this situation.

Choice C: Notifying the provider:

Although the provider should be informed of the situation, checking the tubing for patency is a necessary first step to gather more information and potentially resolve the issue quickly without requiring further intervention.

Choice D: Offering oral fluids:

Increasing fluid intake might be helpful in some cases of decreased urinary output, but it's not the priority action in a patient with a continuous bladder irrigation system and a potential catheter obstruction.

A. Cellular hypoxia B. Fluid retention C. Prolonged bleeding D. Impaired immunity

Correct Answer is A

Explanation

Choice A rationale:

Cellular hypoxia occurs when cells do not receive enough oxygen to meet their metabolic demands. Hemoglobin is the protein in red blood cells that carries oxygen from the lungs to the tissues. A hemoglobin level of 10.8 g/dL is below the normal range for adults (14-18 g/dL), indicating that the client has anemia. Anemia reduces the oxygen-carrying capacity of the blood, which can lead to cellular hypoxia.

Here is a detailed explanation of how anemia can lead to cellular hypoxia:

Decreased oxygen-carrying capacity: Anemia results in fewer red blood cells or reduced hemoglobin levels within those cells. As a consequence, the blood's ability to transport oxygen to the tissues is diminished.

Impaired oxygen delivery: Oxygen is transported to the tissues through the bloodstream, attached to hemoglobin within red blood cells. With fewer red blood cells or reduced hemoglobin, the delivery of oxygen to the tissues is compromised.

Decreased oxygen availability at the cellular level: As oxygen delivery is impaired, less oxygen is available to the cells for metabolic processes. This insufficient oxygen supply leads to cellular hypoxia.

Impaired cellular function: Cells require oxygen to produce energy through a process called aerobic respiration. Cellular hypoxia disrupts this process, leading to impaired cellular function.

Tissue and organ dysfunction: When a significant number of cells within a tissue or organ experience hypoxia, the function of that tissue or organ can be compromised. This can manifest in various symptoms and complications, depending on the affected organs.

Common signs and symptoms of cellular hypoxia:

Fatigue Weakness

Shortness of breath Pale skin

Dizziness Headache Chest pain

Tachycardia (rapid heart rate) Cognitive impairment

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is looking after a patient who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation.The nurse observes that there has been no urinary output in the last hour. What should the nurse do first?

Correct Answer is B

Explanation

A nurse is caring for a client who has a hemoglobin of 10.8 g/dL and a hematocrit of 30%. The nurse should expect the client is at risk for which of the following conditions?

Correct Answer is A

Explanation

A nurse is preparing an in-service presentation about preventing health care-associated infections (HAIs). Which of the following should the nurse include as a common cause of these infections?

In a post-surgical unit, the nurse cares for many patients experiencing pain. Which situation is likely to lower a patient’s pain threshold?

A nurse is caring for a patient on the third day following abdominal surgery. The nurse notes the absence of bowel sounds, abdominal distention, and the patient has not passed any flatus. Which postoperative complication is the patient likely experiencing?

A nurse is caring for a patient who is postoperative following a total knee replacement. What action should the nurse take to prevent deep vein thrombophlebitis?

A nurse is assessing a patient following the removal of the patient’s endotracheal tube. Which finding should the nurse report to the provider?

A nurse is monitoring a patient who is receiving a blood transfusion. Which of the following symptoms should the nurse report to the charge nurse as a sign of an allergic blood transfusion reaction?

A nurse is reinforcing teaching with a client who has peripheral vascular disease (PVD). Which of the following statements by the client indicates a need for further teaching?

A nurse is caring for a group of patients on an adult medical-surgical unit.Which patient should the nurse identify as having the highest risk for aspiration?