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 A
Explanation
Choice A rationale
A WBC count of 2300/mm³ is significantly lower than the normal range (4500-11000/mm³) and indicates leukopenia, which increases the risk of infection. This finding should be reported to the provider.
Choice B rationale
A platelet count of 155,000/mm³ is within the lower end of the normal range (150,000- 450,000/mm³) and does not require immediate reporting.
Choice C rationale
An RBC count of 5 million/mm³ is within the normal range for females (4.2-5.4 million/mm³) and does not require immediate reporting.
Choice D rationale
A hemoglobin level of 12 g/dL is within the normal range for females (12-16 g/dL) and does not require immediate reporting.
Correct Answer is D
Explanation
Choice A rationale
Including fluoridated water in the toddler’s diet does not prevent iron deficiency anemia.
Choice B rationale
Administering fat-soluble vitamins daily is not a method of preventing iron deficiency anemia.
Choice C rationale
Limiting intake of high-protein foods is not related to preventing iron deficiency anemia.
Choice D rationale
Avoiding a diet that consists primarily of milk is recommended because excessive milk intake can interfere with iron absorption and lead to iron deficiency anemia.