Chapter 54 Osborn, Medical-Surgical Nursing, 2e
Question 1 Type: MCSA The nurse would be most alert for assessment findings of hypovolemic shock in which patient? 1. Patient who had a DVT after a surgical procedure 2 years ago 2. Patient 6 hours postmastectomy 3. Patient with coronary atherosclerosis who takes 81 mg of aspirin daily 4. Patient sustaining a transmural myocardial infarction 2 days ago Correct Answer: 2 Rationale 1: A past history of DVT is not pertinent to hemorrhage, as DVT is caused by a clot. Rationale 2: Postoperative patients are at risk for hemorrhage; mastectomy patients typically have drains whose output should be carefully documented. Rationale 3: The antiplatelet properties of aspirin may predispose the patient to bleeding; however, there is no indication of trauma or bleeding. Rationale 4: A myocardial infarction may lead to cardiogenic shock, not hemorrhage. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 54-1
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- 11 de abril de 2021
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