A nurse is providing postoperative care to a client who lost 800 mL of blood during surgery. The client’s blood pressure has been steadily decreasing over the past 2 hours.
Which of the following categories of shock should the nurse recognize is occurring?
Hypovolemic shock.
Septic shock.
Neurogenic shock.
Obstructive shock.
The Correct Answer is C
Choice A rationale
Hypovolemic shock occurs due to a significant decrease in circulating blood volume, leading to inadequate tissue perfusion. Blood loss, such as the 800 mL lost during surgery, is a common cause of hypovolemic shock. The steadily decreasing blood pressure is consistent with this type of shock.
Choice B rationale
Septic shock results from a systemic inflammatory response to infection, leading to vasodilation and maldistribution of blood flow. There is no indication of infection in this scenario.
Choice C rationale
Neurogenic shock results from a loss of sympathetic tone, leading to vasodilation and relative hypovolemia. It is often associated with spinal cord or severe head injury, which is not indicated in this scenario.
Choice D rationale
Obstructive shock occurs when there is an obstruction to blood flow within the cardiovascular system, such as a pulmonary embolism or cardiac tamponade. There is no evidence of such an obstruction in this scenario.
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Correct Answer is D
Explanation
Choice A rationale
Urinary output is an important postoperative assessment, but it is not the highest priority for a client who has undergone a thoracotomy and lobectomy. Monitoring urinary output helps assess kidney function and fluid balance, but it does not directly address the respiratory status, which is critical in this case. The primary concern after thoracotomy and lobectomy is ensuring adequate oxygenation and ventilation, as the surgery directly impacts the lungs and respiratory function.
Choice B rationale
Pain level is a significant postoperative assessment, as effective pain management is crucial for recovery. However, it is not the highest priority in this scenario. While managing pain is essential to prevent complications such as atelectasis (collapse of part of the lung) due to shallow breathing, the immediate focus should be on assessing and maintaining adequate respiratory function. Pain management can be addressed once the client’s respiratory status is stabilized.
Choice C rationale
Chest tube drainage is a critical postoperative assessment for clients who have undergone thoracotomy and lobectomy. Monitoring chest tube output helps detect complications such as bleeding or pneumothorax (air in the pleural space). However, it is not the highest priority compared to arterial blood gases assessment. While chest tube drainage provides valuable information about the client’s condition, arterial blood gases assessment directly measures the client’s oxygenation and ventilation status, which is paramount in the immediate postoperative period.
Choice D rationale
Arterial blood gases (ABG) assessment is the highest priority for a client who is postoperative following a thoracotomy and lobectomy. ABG analysis provides crucial information about the client’s oxygenation, ventilation, and acid-base balance. This assessment helps detect hypoxemia (low blood oxygen levels), hypercapnia (elevated carbon dioxide levels), and respiratory acidosis, which are critical concerns after lung surgery. Ensuring adequate oxygenation and ventilation is the top priority to prevent respiratory complications and support the client’s recovery.
Correct Answer is C
Explanation
Choice A rationale
Maintaining a semi-Fowler’s position can help improve lung expansion and ease breathing in clients with chronic obstructive pulmonary disease (COPD). However, it does not directly address the issue of mucus congestion and difficulty in expectorating (bringing up) mucus.
While positioning can aid in overall respiratory comfort, it is not the most effective intervention for managing mucus congestion in COPD clients.
Choice B rationale
A low-salt diet is beneficial for overall health and can help manage conditions such as hypertension and heart disease. However, it does not have a direct impact on mucus congestion in clients with COPD. Dietary modifications are important for managing comorbidities, but they do not address the primary concern of mucus clearance in this scenario.
Choice C rationale
Encouraging the client to drink 2 to 3 liters of water daily is an effective intervention for managing mucus congestion in clients with COPD. Adequate hydration helps thin the mucus, making it easier to cough up and clear from the airways. This intervention directly addresses the client’s complaint of difficulty in expectorating mucus and can improve respiratory function and comfort.
Choice D rationale
Administering oxygen via nasal cannula at 2 L/min can help improve oxygenation in clients with COPD. However, it does not address the issue of mucus congestion and difficulty in expectorating mucus. While supplemental oxygen is important for managing hypoxemia, it is not the primary intervention for mucus clearance. The focus should be on interventions that help thin and mobilize mucus to alleviate the client’s symptoms.