The surgical ICU nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock?

Tachypnoea

Heart blocks

Vomiting

Bradycardia

Hypotension

Answer and Explanation

The Correct Answer is A

Tachypnoea, which refers to an increased respiratory rate, is an early symptom of hypovolemic shock. It is the body's compensatory response to inadequate tissue perfusion and decreased oxygen delivery. The increased respiratory rate is an attempt to improve oxygenation and maintain vital organ function.
B. Heart blocks in (option B) are incorrect because Heart blocks refer to disruptions in the electrical conduction system of the heart and are not specific to hypovolemic shock.
C. Vomiting in (option C) is incorrect because: Vomiting may occur in various conditions, including shock, but it is not exclusive to hypovolemic shock and can be present in other forms of shock or illnesses.
D. Bradycardia in (option D) is incorrect because Bradycardia, or a slow heart rate, is not typically an early symptom of hypovolemic shock. Instead, tachycardia (rapid heart rate) is more commonly observed as a compensatory response to maintain cardiac output.
E. Hypotension in (option E) is incorrect because Hypotension, or low blood pressure, can occur in hypovolemic shock but is generally considered a later-stage symptom. In the early stages, compensatory mechanisms may help maintain blood pressure, so hypotension may not be present initially.
F. Bradypnea in (option F) is incorrect because: Bradypnea refers to a slow respiratory rate, which is not typically an early symptom of hypovolemic shock. Tachypnoea, as mentioned earlier, is the more common early respiratory symptom.

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Correct Answer is B

Explanation

Cool, clammy skin, tachycardia, and hypotension are signs of shock, indicating inadequate tissue perfusion and oxygenation. The immediate priority is to ensure adequate oxygen delivery to the tissues. Providing oxygen at 100% via a non-rebreather mask helps increase the patient's oxygen saturation and improve tissue oxygenation.
While all the options mentioned are important in the management of a patient in shock, oxygenation takes priority as it directly addresses compromised tissue perfusion and oxygenation.
A. Inserting two large-bore IV catheters in (option A) is incorrect because: Establishing intravenous access is crucial for fluid resuscitation and administration of medications, but it can be done after ensuring adequate oxygenation.
C. Drawing blood to type and crossmatch for transfusions in (option C) is incorrect because Blood typing and crossmatching are important for potential blood transfusions but should not be the first action in this critical situation.
D. Initiating continuous electrocardiogram (ECG) monitoring in (option D) is incorrect because Continuous ECG monitoring is important for assessing cardiac rhythm and detecting any dysrhythmias, but ensuring oxygenation should be the initial priority.
Therefore, in a patient presenting with cool, clammy skin, tachycardia, and hypotension, the nurse should first provide oxygen at 100% via a non-rebreather mask to address inadequate tissue perfusion and oxygenation.

A. Nitroglycerine (Tridil). B. Atenolol (Tenormin). C. Dobutamine (Dobutrex). D. Norepinephrine (Levophed).

Correct Answer is D

Explanation

Norepinephrine is a vasopressor medication commonly used in the management of septic shock. It acts as a potent vasoconstrictor to increase systemic vascular resistance and improve blood pressure. By constricting blood vessels, norepinephrine helps restore tissue perfusion and improve organ function.
A. Nitroglycerine (Tridil) in (option A) is incorrect because: Nitroglycerine is a vasodilator and would further lower blood pressure. It is not suitable for a patient with septic shock who already has low blood pressure.
B. Atenolol (Tenormin) in (option B) is incorrect because: Atenolol is a beta-blocker and would further decrease heart rate and blood pressure. It is not appropriate for a patient in septic shock who requires intervention to increase blood pressure.
C. Dobutamine (Dobutrex) in (option C) is incorrect because: Dobutamine is an inotropic medication used to increase cardiac output. While it can be helpful in certain types of shock, such as cardiogenic shock, it is not the first-line choice for septic shock when there is inadequate blood pressure response.

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The surgical ICU nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock?

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