Hemorrhagic (Hypovolemic) Shock

Question 1 A patient arrives at the emergency department with a large laceration on the thigh and a loss of approximately 800 mL of blood. Which clinical manifestation should the nurse expect if the patient is experiencing hypovolemic shock? A. Hypertension B. Tachycardia C. Bradypnea D. Increased urinary output Correct Answer: B. Tachycardia Rationale: In response to blood loss, the body initiates compensatory mechanisms to maintain cardiac output, including increasing the heart rate (tachycardia). Hypertension would not be expected in hypovolemic shock; instead, hypotension may occur. Bradypnea and increased urinary output are also not typical manifestations of hypovolemic shock. ________________________________________ Question 2 During the assessment of a patient in hypovolemic shock, the nurse notes cool, clammy skin and decreased peripheral pulses. Which action should the nurse take first? A. Administer oxygen. B. Place the patient in a high Fowler’s position. C. Notify the healthcare provider. D. Encourage deep breathing exercises. Correct Answer: A. Administer oxygen Rationale: Hypovolemic shock decreases oxygen delivery to tissues. Providing supplemental oxygen helps optimize tissue oxygenation. High Fowler’s position can worsen hypotension, and notifying the provider would follow, after ensuring patient stability. Deep breathing is not prioritized in this situation. ________________________________________ Question 3 Which nursing diagnosis is the highest priority for a patient experiencing hemorrhagic shock? A. Acute Pain B. Decreased Cardiac Output C. Risk for Infection D. Impaired Physical Mobility Correct Answer: B. Decreased Cardiac Output Rationale: Decreased cardiac output is directly related to the hypovolemia that characterizes hemorrhagic shock and requires prompt intervention to prevent organ failure. Acute pain, infection risk, and mobility concerns are secondary to restoring effective circulation. ________________________________________ Question 4 A patient with hemorrhagic shock requires fluid resuscitation. Which solution should the nurse anticipate administering first? A. 0.9% Normal Saline B. Dextrose 5% in Water (D5W) C. Lactated Ringer's Solution D. Albumin Correct Answer: C. Lactated Ringer's Solution Rationale: Lactated Ringer’s solution is an isotonic crystalloid preferred in hemorrhagic shock for initial fluid resuscitation due to its ability to expand blood volume effectively. D5W is not effective for volume replacement in shock. Albumin may be used later if colloid support is necessary. ________________________________________ Question 5 A patient with hemorrhagic shock has a central venous pressure (CVP) of 2 mm Hg. What should the nurse interpret this finding as? A. Normal volume status B. Overhydration C. Hypovolemia D. Heart failure Correct Answer: C. Hypovolemia Rationale: A CVP of 2 mm Hg is below the normal range (4-12 mm Hg), indicating a decreased blood volume, consistent with hypovolemic shock. Overhydration would increase CVP, while heart failure typically leads to increased CVP as well. ________________________________________ ________________________________________ Question 6 The nurse is monitoring a patient receiving large-volume fluid resuscitation for hemorrhagic shock. Which electrolyte imbalance should the nurse be most concerned about? A. Hyperkalemia B. Hypernatremia C. Hypocalcemia D. Hypercalcemia Correct Answer: C. Hypocalcemia Rationale: Large volumes of fluid, especially if blood products are used, can lead to hypocalcemia due to citrate in transfused blood binding with calcium. Monitoring electrolyte levels is essential to prevent complications. ________________________________________ Question 7 Which of the following lab values is most critical for a nurse to monitor in a patient with hemorrhagic shock? A. Hemoglobin and hematocrit B. Blood glucose C. Serum cholesterol D. Platelet count Correct Answer: A. Hemoglobin and hematocrit Rationale: Hemoglobin and hematocrit levels provide information on blood loss and the severity of anemia. While blood glucose and platelets are important, they are not directly related to assessing blood loss or hypovolemia in hemorrhagic shock. ________________________________________ Question 8 A patient is in the progressive stage of hemorrhagic shock. Which clinical manifestation should the nurse expect? A. Restlessness and anxiety B. Warm, flushed skin C. Cold, clammy skin D. Increased urinary output Correct Answer: C. Cold, clammy skin Rationale: In the progressive stage of shock, blood flow is directed away from non-essential areas, leading to decreased perfusion and cold, clammy skin. Increased urinary output is unlikely due to decreased renal perfusion. ________________________________________ Question 9 A nurse is caring for a trauma patient with hemorrhagic shock who is scheduled to receive packed red blood cells (PRBCs). Which action should the nurse prioritize? A. Administering a diuretic before the transfusion B. Using a 22-gauge needle for transfusion C. Ensuring blood is warmed before transfusion D. Infusing the PRBCs slowly over 4 hours Correct Answer: C. Ensuring blood is warmed before transfusion Rationale: Warming blood helps prevent hypothermia, a concern during massive transfusions, which can exacerbate shock. Large-bore IV access is preferred (e.g., 18-gauge), and transfusions in shock may require faster administration than 4 hours. ________________________________________