The nurse caring for a client in the early stages of hypovolemic shock who is hyperventilating. The nurse monitors for which acid-base imbalance based on this clinical presentation?

Respiratory acidosis.

Respiratory alkalosis.

Metabolic acidosis.

Metabolic alkalosis.

Answer and Explanation

The Correct Answer is B

Choice A reason: Respiratory acidosis. Respiratory acidosis occurs when there is inadequate ventilation, leading to increased carbon dioxide levels in the blood. Hyperventilation would not cause respiratory acidosis.

Choice B reason: Respiratory alkalosis. Hyperventilation results in excessive expulsion of carbon dioxide, leading to a decrease in carbonic acid levels in the blood. This causes respiratory alkalosis, which is expected in the early stages of hypovolemic shock as the body attempts to compensate for decreased oxygen delivery.

Choice C reason: Metabolic acidosis. Metabolic acidosis results from an accumulation of acid or loss of bicarbonate in the body. It is typically seen in the later stages of shock when lactic acid builds up due to anaerobic metabolism.

Choice D reason: Metabolic alkalosis. Metabolic alkalosis occurs due to an excessive loss of acids (e.g., through vomiting) or an accumulation of bicarbonate. Hyperventilation does not cause metabolic alkalosis.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason: Cool, moist skin. Cool, moist skin is an early sign of shock as the body redirects blood flow away from the skin to vital organs. This is part of the body's compensatory mechanisms to maintain perfusion.

Choice B reason: Increased bowel sounds. Bowel sounds typically decrease during shock due to reduced blood flow to the gastrointestinal tract. Increased bowel sounds would not be expected.

Choice C reason: Restlessness. Restlessness is an early sign of shock indicating reduced oxygen delivery to the brain. The body responds by becoming more alert and anxious, reflecting increased sympathetic nervous system activity.

Choice D reason: Increased respiratory rate. An increased respiratory rate is a compensatory mechanism to improve oxygenation and reduce carbon dioxide levels in the blood. This is common in the early stages of shock.

Choice E reason: Decreased blood glucose. Blood glucose levels are generally not an immediate indicator in the early stages of shock. The body's stress response can actually increase blood glucose levels initially.

A. Cyanosis. B. Urticaria. C. Petechiae. D. Ecchymosis.

Correct Answer is B

Explanation

Choice A reason: Cyanosis. Cyanosis, or a bluish tint to the skin, indicates significant hypoxemia or poor oxygenation. While it can occur in severe anaphylaxis, it is not a primary integumentary manifestation.

Choice B reason: Urticaria. Urticaria, or hives, is a common integumentary manifestation of anaphylactic shock. It appears as raised, red, itchy welts on the skin due to an allergic reaction.

Choice C reason: Petechiae. Petechiae are small, pinpoint hemorrhages under the skin and are not typically associated with anaphylactic shock. They are more related to conditions involving bleeding or clotting disorders.

Choice D reason: Ecchymosis. Ecchymosis, or bruising, is not a characteristic manifestation of anaphylactic shock. It is more related to trauma or bleeding disorders.

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The nurse caring for a client in the early stages of hypovolemic shock who is hyperventilating. The nurse monitors for which acid-base imbalance based on this clinical presentation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment findings indicate to the nurse that a client is exhibiting early clinical manifestations of the compensatory stage of shock? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

What is an integumentary manifestation of anaphylactic shock?

Correct Answer is B

Explanation

The nurse is caring for a patient who is the victim of a traumatic motor vehicle accident. Vital signs are: T-98.8°F oral, P-140, B/P-86/52, R-28, pulse oximetry-92% on room air. The nurse would suspect which type of shock?

The nurse is caring for a patient recovering from surgery. What action should the nurse perform to prevent the onset of hypovolemic shock?

What clinical manifestation distinguishes or separates neurogenic shock from other forms of shock?

The compensatory stage of shock results in what assessment findings?

The nurse working in the ICU is receiving a client diagnosed with late septic shock. The nurse correlates which clinical manifestations to this stage of septic shock?

During the initial stage of shock, which manifestation should the nurse monitor for when assessing the client?

What is the initial therapy of choice for the treatment of anaphylactic shock?

The nurse is caring for a patient who is the victim of a traumatic motor vehicle accident. Vital signs are: T-98.8 oral, P-140, B/P-86/52, R-28, pulse oximetry-92% on room air. The nurse would suspect which type of shock?