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. Cortisol levels are not directly affected by furosemide; monitoring for adrenal function is not a priority.
B. Bicarbonate levels are not specifically monitored for clients on furosemide; this medication's main effect does not relate directly to bicarbonate balance.
C. Albumin levels are not primarily affected by furosemide; although low albumin can affect fluid status, it is not the critical monitoring focus.
D. Potassium levels should be monitored because furosemide is a loop diuretic that can lead to hypokalemia, which is a common and significant side effect due to increased renal excretion of potassium.
Correct Answer is A
Explanation
A. The CD4-T-cell count of 180 cells/mm3 is a critical measure of immune function in an HIV-positive client, indicating progression of the disease and risk for opportunistic infections. Values below 200 cells/mm3 signify the client has progressed to AIDS.
B. A positive Western blot test confirms the presence of HIV but does not indicate the immediate health risk or necessary interventions.
C. A platelet count of 150,000/mm3 is within the normal range, thus not indicative of any urgent concerns.
D. A WBC count of 5,000/mm3 is also within normal limits and does not highlight an immediate issue that needs addressing compared to the CD4 count.