A practical nurse is monitoring a client who recently returned from the post-anesthesia ca… — NCLEX-PN

A practical nurse is monitoring a client who recently returned from the post-anesthesia care unit following abdominal surgery. Which of the following assessment findings should the nurse identify as early indicators of hypovolemic shock? (Select all that apply.)

Heart rate of $118$ beats per minuteCevap
Blood pressure decreasing from $128/82\text{ mm Hg}$ to $98/60\text{ mm Hg}$ Cevap
Client reports of sudden, severe thirstCevap
D
Client reports of moderate incisional pain
E
Axillary temperature of $37.3^\circ\text{C}$ ( $99.1^\circ\text{F}$ )

Cevap

The findings that indicate early hypovolemic shock are a heart rate of 118 beats per minute, a blood pressure decreasing from 128/82 mm Hg to 98/60 mm Hg, and client reports of sudden, severe thirst.

Early signs of hypovolemic shock include compensatory mechanisms such as an elevated heart rate (tachycardia) and severe thirst as the body attempts to maintain circulating volume and cardiac output. A subsequent drop in blood pressure confirms that the cardiovascular system is struggling to adapt to the fluid loss. Recognizing this cluster of findings is crucial for early intervention.

Adım Adım Çözüm

Analyze the clinical scenario and the client's current risk factors.

The client is in the early postoperative phase, making them highly vulnerable to hemorrhage and subsequent fluid volume deficit.

Understanding the primary postoperative risks directs the nurse to monitor specific physiological adaptations.

Evaluate the assessment findings against the clinical signs of circulatory compromise.

Tachycardia, dropping blood pressure, and intense thirst are identified as classic signs of reduced circulating blood volume.

The body compensates for fluid loss by increasing the heart rate and triggering the thirst mechanism before ultimately failing to maintain blood pressure.

Differentiate acute signs of deterioration from expected postoperative findings.

Incisional pain and a low-grade temperature are excluded as indicators of shock because they are expected responses to surgical trauma.

This ensures the nurse prioritizes potentially life-threatening circulatory changes over routine, stable postoperative symptoms.

Anahtar Kavram

Early recognition of hypovolemic shock involves identifying compensatory cardiovascular changes such as tachycardia, hypotension, and systemic responses like thirst.

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