A client experiencing trauma begins to show early signs of ...

[karen]

A client experiencing trauma begins to show early signs of hypovolemic shock. Before notifying the medical team, what should the nurse do first?
 
  1. Raise the head of the bed.
  2. Turn the client to Sims' position.
  3. Establish responsiveness.
  4. Place the client on 12-15 L/minute of oxygen.

Question 2

The nurse is monitoring a client who is receiving a colloid infusion. For which reason should the nurse notify the health care provider?
 
  1. A normal body temperature
  2. Urine output of 35 mL/hour
  3. Cough and wheezing
  4. Abnormally dry skin

[ebenov]

Answer to Question 1

Answer: 4

1. The immediate need of the client who is experiencing early shock is oxygen to prevent damage to the cells. Raising the head of the bed is not the priority intervention.
2. Administering oxygen takes precedence over positioning.
3. The client in early shock is usually conscious but restless.
4. Because of the blood loss, the cells of the body are receiving little oxygen. The first action of the nurse is to start the client on oxygen to prevent cell and tissue damage.

Answer to Question 2

Answer: 3

1. A client who is experiencing a reaction to a colloid solution will have an increased temperature.
2. Urine output of 35 mL/hour is acceptable.
3. Cough and wheezing are an indication that the client is experiencing fluid overload and has excess fluid accumulating in the lungs.
4. The client in shock might have dry skin until lost fluids have been replaced.

[karen]

Excellent

[kjohnson]

TYSM