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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
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
Explanation
Choice A rationale
Giving the child acetaminophen for discomfort is appropriate as it helps manage pain without interfering with the healing process.
Choice B rationale
Keeping the child home for 1 week is not necessary unless there are specific complications or instructions from the healthcare provider.
Choice C rationale
Assisting the child to take a tub bath for the first 3 days is not recommended as it may increase the risk of infection at the catheter insertion site.
Choice D rationale
Offering the child clear liquids for the first 24 hours is not necessary unless there are specific dietary restrictions from the healthcare provider.