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 A
Explanation
Choice A reason: Consuming alcohol as a coping mechanism for stress, especially before work, is concerning and unprofessional for a healthcare provider, as it can impair judgment and performance.
Choice B reason: Seeking advice from friends before asking someone out is a common social behavior and not typically a cause for concern.
Choice C reason: Taking deep breaths to manage anxiety is a healthy coping strategy and is not a cause for concern.
Choice D reason: Studying late into the night might indicate a high level of dedication or poor time management, but it is not inherently concerning unless it leads to chronic sleep deprivation.
Correct Answer is A
Explanation
Choice A reason: Informed consent is obtained when a patient agrees to a procedure after understanding its risks and benefits, which is what Melva provided.
Choice B reason: A time out is a final review before surgery to ensure correct patient identity, procedure, and site, which is not described here.
Choice C reason: Patient history refers to the collection of a patient's medical background, which is not the focus in this scenario.
Choice D reason: The pre-op checklist is a list of tasks to be completed before surgery, not a discussion of the procedure itself.
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