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NurseDive Free Nursing Practice Question
A nurse is caring for a client who returns to the nursing unit from the recovery room after a sigmoid colon resection for adenocarcinoma. The client had an episode of intraoperative bleeding. Which finding indicates to the nurse that the client may be developing hypovolemic shock?
A. Decrease in the urinary output from 50 mL to 30 mL per hour.
A decrease in urinary output can be a sign of decreased blood volume but is less immediate than changes in heart rate.
B. Increase in the heart rate from 88 to 110/min.
An increase in the heart rate is a common compensatory response to hypovolemia as the body attempts to maintain adequate perfusion to vital organs.
C. Decrease in the respiratory rate from 20 to 16/min.
A decrease in the respiratory rate is not typically associated with hypovolemic shock; rather, respiratory rate may increase due to compensatory mechanisms.
D. Increase in the temperature from 37.5° C (99.5° F) to 38.6° C (101.5° F).
An increase in temperature is not a specific indicator of hypovolemic shock; it could be related to infection or inflammation rather than immediate hypovolemia.
This question is an excerpt from Nurse Dive's nursing test bank - Ati critical care midterm proctored exam. Take the full exam now
Full Explanation
A. A decrease in urinary output can be a sign of decreased blood volume but is less immediate than changes in heart rate.
B. An increase in the heart rate is a common compensatory response to hypovolemia as the body attempts to maintain adequate perfusion to vital organs.
C. A decrease in the respiratory rate is not typically associated with hypovolemic shock; rather, respiratory rate may increase due to compensatory mechanisms.
D. An increase in temperature is not a specific indicator of hypovolemic shock; it could be related to infection or inflammation rather than immediate hypovolemia.
Similar Questions
A nurse is selecting a qualified staff member to double-check a blood label with a client ID bracelet prior to infusing a unit of blood. The nurse should identify that which of the following persons is qualified?
A. Assistive personnel
Assistive personnel typically do not have the training or authority to perform the critical double-check of blood products.
B. Oncology nurse
An oncology nurse is a qualified staff member who has the necessary training and experience to correctly verify blood labels and client ID bracelets before transfusion.
C. Phlebotomist
A phlebotomist is trained in blood collection but is not generally authorized to perform blood transfusion verifications.
D. Senior nursing student
A senior nursing student may not have the required certification or experience to safely double-check blood transfusion products.
Full Explanation
A. Assistive personnel typically do not have the training or authority to perform the critical double-check of blood products.
B. An oncology nurse is a qualified staff member who has the necessary training and experience to correctly verify blood labels and client ID bracelets before transfusion.
C. A phlebotomist is trained in blood collection but is not generally authorized to perform blood transfusion verifications.
D. A senior nursing student may not have the required certification or experience to safely double-check blood transfusion products.
A nurse is caring for a client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea and weakness. Which of the following actions should the nurse take first?
A. Suggest that the client rests before eating the meal.
While rest might help, it does not address the underlying issues of nausea and weakness that could be related to digoxin toxicity or another urgent condition.
B. Request a dietitian consult.
A dietitian consult is not immediate or necessary at this moment; the priority is to assess the client's current symptoms.
C. Check the client's vital signs.
Checking the client’s vital signs is the first action to identify if there are any abnormal findings such as bradycardia or other signs of digoxin toxicity, which could be causing the symptoms.
D. Request an order for an antiemetic.
Requesting an antiemetic might be appropriate if nausea is confirmed, but the priority is to first assess the client’s vital signs to rule out serious issues.
Full Explanation
A. While rest might help, it does not address the underlying issues of nausea and weakness that could be related to digoxin toxicity or another urgent condition.
B. A dietitian consult is not immediate or necessary at this moment; the priority is to assess the client's current symptoms.
C. Checking the client’s vital signs is the first action to identify if there are any abnormal findings such as bradycardia or other signs of digoxin toxicity, which could be causing the symptoms.
D. Requesting an antiemetic might be appropriate if nausea is confirmed, but the priority is to first assess the client’s vital signs to rule out serious issues.
A nurse is caring for a client who has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
A. Confusion
Confusion is not a typical manifestation of myasthenia gravis but could be related to other issues or conditions.
B. Increased urinary output
Increased urinary output is not directly associated with myasthenia gravis and is not a primary symptom to monitor.
C. Increased intracranial pressure
Increased intracranial pressure is not characteristic of myasthenia gravis and is unrelated to the condition.
D. Weakness
Weakness is a hallmark symptom of myasthenia gravis, resulting from impaired communication between nerves and muscles. It is crucial to monitor and assess for changes in muscle strength and fatigue.
Full Explanation
A. Confusion is not a typical manifestation of myasthenia gravis but could be related to other issues or conditions.
B. Increased urinary output is not directly associated with myasthenia gravis and is not a primary symptom to monitor.
C. Increased intracranial pressure is not characteristic of myasthenia gravis and is unrelated to the condition.
D. Weakness is a hallmark symptom of myasthenia gravis, resulting from impaired communication between nerves and muscles. It is crucial to monitor and assess for changes in muscle strength and fatigue.