The nurse is caring for a client who has hemorrhaged postoperatively and is in an early stage of shock. Which cardiopulmonary symptoms are most indicative of progressive hypovolemic shock?
Narrowed pulse pressure, presence of 3+ femoral pulses, apneic episodes.
Widening pulse pressure, muffled heart sounds, presence of atrial gallop.
Increased heart rate, lowered systolic reading, peripheral extremity mottling.
Irregular heart rate, elevated diastolic reading, increased respiratory rate.
The Correct Answer is C
A. Narrowed pulse pressure, presence of 3+ femoral pulses, apneic episodes. Narrowed pulse pressure is consistent with hypovolemic shock, but 3+ femoral pulses are not expected, as shock leads to weak, thready pulses due to reduced perfusion. Apneic episodes typically occur in the late stages of shock, not in the early or progressive stages.
B. Widening pulse pressure, muffled heart sounds, presence of atrial gallop. A widening pulse pressure and muffled heart sounds are more indicative of cardiac tamponade, not hypovolemic shock. Hypovolemic shock is characterized by a narrowing pulse pressure due to a drop in systolic blood pressure while diastolic pressure remains relatively stable.
C. Increased heart rate, lowered systolic reading, peripheral extremity mottling. Tachycardia is an early compensatory response to hypovolemia as the body attempts to maintain cardiac output. As shock progresses, systolic blood pressure drops due to inadequate circulating volume. Peripheral extremity mottling occurs as the body shunts blood to vital organs, reducing perfusion to the skin. These signs are characteristic of progressive hypovolemic shock.
D. Irregular heart rate, elevated diastolic reading, increased respiratory rate. An irregular heart rate is not a primary indicator of hypovolemic shock. While respiratory rate increases in response to decreased oxygen delivery, an elevated diastolic reading is uncommon, as diastolic pressure tends to stay stable or decrease slightly with ongoing hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Insert a large bore peripheral IV catheter. The client is showing signs of shock (tachycardia, hypotension, tachypnea) likely due to envenomation and systemic venom effects. Rapid IV access is essential for fluid resuscitation, administration of antivenom, and management of shock. A large bore (18-gauge or larger) IV catheter allows for aggressive fluid therapy to maintain perfusion and prevent circulatory collapse.
B. Raise extremity above the heart. Elevating the limb can increase venom circulation, worsening systemic effects. Instead, the affected extremity should be kept at heart level to slow venom spread while ensuring adequate perfusion.
C. Tighten the cloth around the leg. Further tightening the makeshift tourniquet can lead to vascular compromise, ischemia, and increased local tissue damage. Modern guidelines discourage tourniquets as they do not prevent venom spread effectively and may worsen outcomes. The best approach is to loosen or remove restrictive bindings and keep the limb immobilized at heart level.
D. Apply ice over the bite mark. Cold therapy is contraindicated as it can worsen tissue damage by causing vasoconstriction, trapping venom, and increasing necrosis. Instead, the priority is IV access, fluid resuscitation, and preparing for possible antivenom administration.
Correct Answer is D
Explanation
A. Heparin is infused in less than four hours. The heparinized solution used in an intra-arterial (IA) pressure infuser is not intended for systemic anticoagulation but rather to maintain catheter patency. The infusion rate is typically slow and continuous, and completing the infusion in less than four hours is not an indicator of effectiveness.
B. Systolic blood pressure greater than 120 mm Hg. Heparin in an IA pressure infuser does not directly affect blood pressure. Its purpose is to prevent clot formation within the catheter, ensuring uninterrupted arterial pressure monitoring. BP readings are monitored separately and are not an indicator of heparin’s therapeutic effect.
C. No knee pain upon forced dorsiflexion. This assessment is used to evaluate deep vein thrombosis (DVT) (Homan's sign), which is not related to arterial catheter function. The low-dose heparin in the pressure infuser does not provide systemic anticoagulation, making this finding irrelevant.
D. Intra-arterial cannula remains patent. The primary purpose of heparinized flush solutions in IA lines is to prevent clot formation within the catheter and maintain patency for continuous blood pressure monitoring or arterial blood sampling. A patent arterial line confirms that the heparin infusion is achieving its intended effect.
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