During the refractory stage of shock in hypovolemia, which of the following responses accurately describes the physiological changes that occur?

Increased cardiac output and improved tissue perfusion

Restored fluid balance and resolution of hypovolemia

Worsening organ dysfunction and failure

Decreased heart rate and improved blood pressure

Answer and Explanation

The Correct Answer is C

A. In the refractory stage, cardiac output is decreased and tissue perfusion is severely impaired, not improved.
B. Fluid balance is not restored during the refractory stage; instead, hypovolemia worsens.
C. The refractory stage is characterized by irreversible damage with worsening organ dysfunction and failure despite interventions.
D. Heart rate usually increases initially, and blood pressure typically decreases; decreased heart rate and improved blood pressure are not features of this stage.

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Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

The nurse should monitor the client for pneumothorax and lead dislodgement following permanent pacemaker placement.

Rationale

Pneumothorax: The procedure involves central venous access, often via the subclavian vein, which increases the risk of puncturing the pleura and causing a pneumothorax. Signs include:

Lead dislodgement: Movement or tension on the pacing lead can result in loss of pacemaker capture or failure to pace effectively. This is a priority during the first 24 hours. Indicators include:

A. Will stabilize and be released by tomorrow B. Is in the irreversible stage of shock C. Is in the progressive stage of shock D. Is in the compensatory stage of shock

Correct Answer is C

Explanation

A. A client showing signs of shock (e.g., cold, clammy skin, decreased bowel sounds, tachycardia) is not likely to stabilize and be released by the next day without intensive treatment.
B. The irreversible stage of shock is marked by profound hypotension, multi-organ failure, and unresponsiveness—more severe than this client’s current status.
C. The progressive stage of shock is characterized by impaired tissue perfusion, cold and clammy skin, tachycardia, hypoactive bowel sounds, and early signs of organ dysfunction. Even though the blood pressure is currently normal, perfusion is inadequate.
D. The compensatory stage is earlier and includes signs like tachycardia and restlessness, but perfusion to vital organs is still maintained, and skin may remain warm. This client’s cold skin and decreased bowel sounds suggest progression beyond this stage.

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During the refractory stage of shock in hypovolemia, which of the following responses accurately describes the physiological changes that occur?

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

A 57-year-old-client is being admitted to the intensive care unit (ICU) with a diagnosis of possible septic shock He has a normal blood pressure, increased heart rate, decreased bowel sounds, and their skin is cold and clammy. The ICU nurse suspects the client:

Correct Answer is C

Explanation

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