The nurse is caring for a 52-year-old male patient with a bowel obstruction. Which of these signs would be the earliest indicator to the nurse that the patient is developing symptoms of shock?
Urine output 18 mL/hr.
Blood pressure 88/50 mmHg.
Lethargy.
Pulse 110 bpm.
The Correct Answer is A
Choice A reason: A urine output of 18 mL/hr is significantly lower than the normal range (typically around 0.5-1 mL/kg/hr), indicating possible renal hypoperfusion, an early sign of shock.
Choice B reason: While blood pressure is an important indicator, it may not drop until later stages of shock.
Choice C reason: Lethargy can be a sign of shock, but it is a more subjective and later symptom compared to the objective measure of urine output.
Choice D reason: An elevated pulse is a compensatory mechanism in shock, but it is not as specific an early indicator as a decrease in urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Debridement is not related to dosing, which typically refers to medication administration.
Choice B reason: While debridement may involve cleaning dirty wounds, this choice does not fully capture the definition of debridement.
Choice C reason: Debridement is the medical process of removing dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue.
Choice D reason: Infected wounds may require debridement, but this choice does not define what debridement is.
Correct Answer is D
Explanation
Choice A reason: This statement is incorrect because it suggests that higher oxygen levels trigger breathing, which is not the case in hypoxic drive.
Choice B reason: While carbon dioxide levels do influence breathing, this statement is not accurate in the context of hypoxic drive, which is specifically about oxygen levels.
Choice C reason: This choice is incorrect because the client does notice the need to breathe, but the trigger is low oxygen rather than high carbon dioxide levels.
Choice D reason: This is correct. In clients with COPD, chronic high levels of carbon dioxide can lead to a reliance on low oxygen levels to stimulate breathing.
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