What is the earliest sign of shock that the nurse would monitor for during a routine assessment?

Restlessness

Pale skin

Complaints of thirst

Complaints of nausea

Answer and Explanation

The Correct Answer is A

A) Restlessness.
Restlessness is often one of the earliest signs of shock. It reflects the body's attempt to compensate for decreased tissue perfusion and oxygen delivery by increasing sympathetic nervous system activity. Restlessness may manifest as agitation, fidgeting, or an inability to sit still. It is an important clinical indicator that suggests impending hemodynamic instability and warrants prompt assessment and intervention.

B) Pale skin:
Pale skin is a common sign of shock, but it may not always be the earliest manifestation. Pale skin typically occurs later in the progression of shock as vasoconstriction occurs, redirecting blood flow away from the skin to vital organs in an attempt to maintain perfusion.

C) Complaints of thirst:
While complaints of thirst may indicate dehydration or fluid loss, they are not typically considered the earliest sign of shock. Thirst usually occurs after the body has already begun to experience fluid deficit and may not be apparent until shock is more advanced.

D) Complaints of nausea:
Nausea may occur in shock due to decreased perfusion to the gastrointestinal tract, but it is not usually the earliest sign. Nausea may develop as shock progresses and metabolic disturbances worsen, but it is often preceded by other symptoms such as restlessness or altered mental status.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A) This is normal.
Guaifenesin is an expectorant medication commonly used to help loosen and thin mucus in the airways, making it easier to cough up. Coughing up phlegm after taking guaifenesin is an expected response and indicates that the medication is working as intended. Guaifenesin helps to clear the airways of excess mucus, which can be particularly beneficial for individuals with respiratory conditions such as bronchitis or chest congestion.

B) This requires further investigation.
Coughing up phlegm after taking guaifenesin is a common and expected response and does not typically indicate a need for further investigation unless there are other concerning symptoms present. It is important for the nurse to provide reassurance and education about the expected effects of the medication.

C) This is indicative of an allergic reaction.
Coughing up phlegm after taking guaifenesin is not indicative of an allergic reaction. Allergic reactions to guaifenesin are rare but may include symptoms such as rash, itching, swelling, dizziness, or difficulty breathing. If the client were experiencing these symptoms, it would be important to assess further for a possible allergic reaction and intervene accordingly.

D) This means there is probably more pathology present.
Coughing up phlegm after taking guaifenesin does not necessarily indicate the presence of more pathology. It simply indicates that the medication is helping to loosen and mobilize mucus in the airways, which is a normal response to expectorant therapy. If the client has concerns about their symptoms, further assessment by a healthcare provider may be warranted, but coughing up phlegm alone is not necessarily indicative of worsening pathology.

Correct Answer is ["5"]

Explanation

To determine how many hours it will take for the IV pump to infuse the 1000 mL bag of 0.9% sodium chloride at a rate of 200 mL/hr, we can use the following formula:

Time (hr) = Volume (mL)/Rate (mL/hr)

Given:

Volume = 1000 mL

Rate = 200 mL/hr

Substitute the given values into the formula:

Time (hr)=1000 mL/200 mL/hr

Time (hr)=5hours

Rounding to the nearest whole number, the IV pump will infuse over 5 hours.

Therefore, the nurse should expect the IV pump to infuse over 5 hours.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

What is the earliest sign of shock that the nurse would monitor for during a routine assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After taking the medication guaifenesin (Mucinex), the client complains of coughing up phlegm. What is the best response by the nurse?

Correct Answer is A

Explanation

Correct Answer is ["5"]

Explanation

A client presents with shock in the hospital, and has a history of a recent infection. What does the nurse suspect that this client is experiencing:

A client has been diagnosed with allergic rhinitis. Which symptoms would the nurse expect to observe? (Select All that Apply.)

A client asks the nurse what ventilation is. What is the most appropriate response by the nurse?

A nurse is preparing to administer valproic acid 500 mg PO. Available is valproic acid oral solution 250 mg/5 mL. How many mL should they administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply.)

A nurse is preparing to administer amoxicillin 500 mg PO to a client. The amount available is amoxicillin suspension 250 mg/5 ml. How should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)

Which type of laxative causes peristalsis by irritating the bowel?

What is the earliest sign of shock that the nurse would monitor for during a routine assessment?