The nurse is caring for an elderly client with type II diabetes who has had nausea, vomiting and diarrhea for several days and who now is disoriented and listless. Initial vital signs: B/P 72/62, pulse 146 irregular and thready, respirations 38 breaths per minute and shallow, and temperature of 97.0 F rectally. The skin is cool and clammy. The nurse recognizes that this client's symptoms are most indicative of which stage and type of shock? The:

initial stage of septic shock.

refractory stage of obstructive shock.

progressive stage of hypovolemic shock.

compensatory stage of diabetic shock.

Answer and Explanation

The Correct Answer is C

A. Initial stage of septic shock

Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.

B. Refractory stage of obstructive shock

Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.

C. Progressive stage of hypovolemic shock

The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).

D. Compensatory stage of diabetic shock

"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.

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Correct Answer is D

Explanation

A. Continue to monitor the client as a paralytic ileus is possible

Paralytic ileus can occur postoperatively, but sudden severe pain and distension indicate a more serious issue, such as bowel infarction.

B. Administer the PRN stool softener to the client

A stool softener is inappropriate if the client has a possible bowel obstruction or ischemia.

C. Obtain an order to insert a nasogastric tube set to low suction

An NG tube may help relieve distension, but it does not treat the underlying cause. The priority is to notify the surgeon.

D. Report the assessment findings to the surgeon

Absent bowel sounds, severe pain, and distension suggest bowel ischemia, a life-threatening complication requiring immediate surgical intervention.

A. Elevate the extremity and apply an ice pack to the injured area B. Contact poison control to determine the best neutralizing agent C. Apply a sterile dressing, wrapping the fingers separately D. Irrigate the affected area with room temperature water

Correct Answer is D

Explanation

A. Elevate the extremity and apply an ice pack to the injured area

Elevating the extremity can help reduce swelling, but applying ice is not recommended for chemical burns as it can cause further tissue damage.

B. Contact poison control to determine the best neutralizing agent

While contacting poison control is important, it should not be the immediate first action in an emergency setting.

C. Apply a sterile dressing, wrapping the fingers separately

This is important for protecting the wound, but it is not the immediate first action needed for chemical burns.

D. Irrigate the affected area with room temperature water

Immediate irrigation with room temperature water helps to remove the chemical from the skin and dilute its effect, which is the first critical step in managing a chemical burn.

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Naxlex Comprehensive Predictor Exams

The nurse cannot auscultate bowel sounds during the assessment of a client who has had a repair of an abdominal aortic aneurysm four days ago. The client is complaining of severe abdominal pain and the abdomen is distended. What action should the nurse take at this time?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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