A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?
Flushing of the skin
Oliguria
Bradypnea
Hypertension
The Correct Answer is B
A. Flushing of the skin is not typical in hypovolemic shock; rather, the skin is usually cool and clammy due to vasoconstriction.
B. Oliguria, or decreased urine output, is expected in hypovolemic shock as the kidneys receive less blood flow, leading to reduced urine production.
C. Bradypnea is not a common finding in hypovolemic shock; instead, tachypnea (increased respiratory rate) is typically observed due to compensatory mechanisms for hypoxia and acidosis.
D. Hypertension is not expected in hypovolemic shock; instead, the client typically presents with hypotension due to decreased blood volume and pressure.
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Correct Answer is D
Explanation
A. Encouraging oral intake may not be effective due to the patient's likely need for more rapid rehydration given his low blood pressure and heart rate.
B. A potassium-sparing diuretic is inappropriate in this situation, as the patient is already experiencing fluid loss and requires rehydration, not diuresis.
C. Restricting fluid intake would be contraindicated as the patient is in a state of dehydration and hypotension.
D. Administering an IV bolus of normal saline is the priority intervention to quickly restore fluid volume and improve blood pressure and hydration status.
Correct Answer is C
Explanation
A. Obstructive shock occurs when blood flow is physically obstructed, such as in cases of pulmonary embolism or cardiac tamponade, which is not indicated here as the cause is blood loss.
B. Septic shock is related to infection and systemic inflammatory response, not directly caused by blood loss.
C. Hypovolemic shock is caused by a significant loss of blood volume, leading to decreased blood pressure, which directly relates to the client losing 800 mL of blood during surgery. This condition results in inadequate perfusion and oxygen delivery to tissues.
D. Neurogenic shock results from spinal cord injuries leading to vasodilation and bradycardia, which is not applicable to this scenario.