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 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.
Correct Answer is D
Explanation
Choice A reason: While bulimia can contribute to gastrointestinal issues, it is not as directly linked to peptic ulcers as the use of nonsteroidal anti-inflammatory drugs (NSAIDs).
Choice B reason: Drinking green tea is not typically associated with an increased risk of peptic ulcers.
Choice C reason: Consuming spicy foods is a commonly believed risk factor, but it is not supported by strong evidence as a direct cause of peptic ulcers.
Choice D reason: The use of NSAIDs, such as ibuprofen, is a well-established risk factor for the development of peptic ulcers due to their effect on the stomach lining.
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