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 C
Explanation
Choice A rationale
Bubbling of the water in the water seal chamber with exhalation. This statement is incorrect. Bubbling in the water seal chamber with exhalation can be normal and indicates that air is being expelled from the pleural space. It is not necessarily a cause for concern.
Choice B rationale
Eyelets are not visible. This statement is incorrect. The visibility of eyelets on the chest tube is not a standard indicator for notifying the provider. The focus should be on the function of the chest tube and the patient’s clinical status.
Choice C rationale
Movement of the trachea toward the unaffected side. This statement is correct. Tracheal deviation toward the unaffected side can indicate a tension pneumothorax, a life-threatening condition that requires immediate medical attention. It suggests that pressure is building up in the pleural space, compressing the lung and shifting the trachea.
Choice D rationale
Crepitus in the area above and surrounding the insertion site. This statement is incorrect. Crepitus, or subcutaneous emphysema, can occur when air leaks into the subcutaneous tissue around the chest tube insertion site. While it should be monitored, it is not necessarily an emergency requiring immediate notification of the provider. .
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Encouraging the client to increase fluid intake is correct. Increasing fluid intake helps to maintain hydration, which is essential for the body to function properly, especially when the client is experiencing fever and muscle aches. Hydration helps to thin mucus, making it easier to expel, and supports the immune system in fighting off infection.
Choice B rationale
Placing the client in a private room is correct. A private room helps to prevent the spread of infection to other patients and healthcare workers. This is particularly important when the client has symptoms such as fever, sore throat, and fatigue, which could indicate a contagious illness.
Choice C rationale
Placing the client on contact precautions is incorrect. Contact precautions are typically used for infections that are spread by direct contact with the patient or their environment, such as MRSA or C. difficile. The symptoms described (headache, muscle aches, fever, sore throat, and fatigue) do not necessarily indicate an infection that requires contact precautions.
Choice D rationale
Wearing a mask when caring for the client is correct. Wearing a mask helps to prevent the transmission of respiratory infections, which can be spread through droplets when the client coughs or sneezes. This is especially important when the client has symptoms such as a sore throat and fever, which could indicate a respiratory infection.