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. A patient with active gastrointestinal bleeding is being monitored for complications. Which of the following signs indicates the patient is developing hypovolemic shock?

A.

Elevated blood pressure

B.

warm, flushed skin

C.

Increased urine output

D.

Increased heart rate

Answer and Explanation

The Correct Answer is D

A. Elevated blood pressure. Blood pressure typically drops in hypovolemic shock as blood volume decreases.

 

B. Warm, flushed skin. As hypovolemic shock progresses, skin becomes cool and clammy due to decreased blood flow and compensatory vasoconstriction.

 

C. Increased urine output. Hypovolemic shock leads to decreased urine output due to reduced renal perfusion.

 

D. Increased heart rate. An increased heart rate is an early compensatory response in hypovolemic shock as the body attempts to maintain cardiac output.


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Correct Answer is C

Explanation

A. Initiate intravenous fluid therapy. While fluid therapy is essential to support circulation and reduce the risk of shock, oxygenation takes priority in fat embolism management.

B. Prepare the client for emergency surgery. Surgery is not typically the first-line intervention for fat embolism; management focuses on supportive care, particularly respiratory support.

C. Administer high-flow oxygen via a non-rebreather mask. High-flow oxygen is the first priority to address hypoxia caused by fat embolism and should be administered immediately to maintain adequate oxygenation.

D. Apply sequential compression devices (SCDs). SCDs are used to prevent venous thromboembolism, but they do not help with the treatment of fat embolism.

Correct Answer is D

Explanation

A. I need to monitor the puncture site for signs of infection such as redness or swelling. Monitoring the puncture site is crucial for detecting any signs of infection or complications, which the patient should be aware of.

B. I should follow a heart-healthy diet to support my recovery. A heart-healthy diet is recommended to manage cholesterol levels and prevent further coronary artery disease progression.

C. I will take my prescribed medications as directed by my doctor. Following the medication regimen is important for preventing complications and supporting recovery, especially for blood thinners or other cardiac medications.

D. I can resume my regular physical activities immediately after I get home. This statement indicates a need for further teaching, as patients should gradually resume physical activities and avoid strenuous activities immediately after PTCA to prevent complications, such as bleeding at the catheter insertion site.

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