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.

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Correct Answer is ["28"]

Explanation

To calculate the IV infusion rate in drops per minute (gtt/min), you can use the following formula:

IV infusion rate (gtt/min) =(Total volume (mL)×Drop factor (gtt/mL)) / Total time (min)

Given:

Total volume = 1000 mL

Drop factor = 10 gtt/mL

Total time = 6 hours = 6 hours × 60 minutes/hour = 360 minutes

Substitute the given values into the formula:

IV infusion rate (gtt/min) = (1000mL×10gtt/mL)/360 min

IV infusion rate (gtt/min) = 10,000/360

$IV infusion rate (gtt/min)≈27.78gtt/min$

Rounding to the nearest whole number, the IV infusion rate is approximately 28 gtt/min

A. Chronic diarrhea B. Chronic constipation C. Frequent vomiting D. Chronic nausea

Correct Answer is B

Explanation

A) Chronic diarrhea:
Overuse of laxatives is more likely to lead to chronic constipation rather than chronic diarrhea. Laxatives are typically used to treat constipation by promoting bowel movements, but overuse can disrupt normal bowel function and result in long-term constipation.

B) Chronic constipation.
Overuse of laxatives can lead to dependence on laxatives for bowel movements and can cause the smooth muscle in the colon to become less responsive to normal stimuli, resulting in decreased muscle tone. This can eventually lead to chronic constipation, where the colon becomes less effective at moving stool through the digestive tract, resulting in infrequent or difficult bowel movements.

C) Frequent vomiting:
Overuse of laxatives does not typically lead to frequent vomiting. Vomiting is more commonly associated with conditions affecting the upper gastrointestinal tract, such as gastroenteritis, gastritis, or other gastrointestinal disorders.

D) Chronic nausea:
Overuse of laxatives may cause gastrointestinal discomfort or upset stomach, but it is not typically associated with chronic nausea. Chronic nausea may be caused by various factors such as gastrointestinal disorders, medications, or other underlying medical conditions unrelated to laxative use.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer 1.000 mL of lactated Ringer's IV over 6 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it appl use a trailing zero.)

Correct Answer is ["28"]

Explanation

Patients should be advised not to overuse laxatives, because the smooth muscle in the colon can lose its tone. What condition should the nurse warn the client can occur if this happens?

Correct Answer is B

Explanation

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