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 B
Explanation
A. Metabolic alkalosis is characterized by an increased pH and increased HCO3 levels, which does not fit the provided values.
B. The low HCO3 of 18 mEq indicates a metabolic acidosis, as the body is unable to retain enough bicarbonate to balance the acid levels, and the pH is also low at 7.30, confirming acidosis.
C. Respiratory alkalosis would show a high pH and low PaCO2, which is not the case here.
D. Respiratory acidosis would be indicated by a high PaCO2 and a low pH, but the HCO3 level is low, indicating a metabolic issue rather than a respiratory one.
Correct Answer is C
Explanation
A. Anuria, or the absence of urine output, indicates significant renal impairment and is a later sign of shock.
B. Hypotension is a classic sign of shock but occurs after compensatory mechanisms have failed.
C. An increased respiratory rate is often one of the earliest indicators of shock, as the body attempts to compensate for reduced oxygenation and tissue perfusion by increasing respiratory effort.
D. A decreased level of consciousness can occur with prolonged shock but typically presents after other compensatory mechanisms have been overwhelmed.