Despite aggressive treatment, the condition of a patient in shock continues to worsen. Surgical intervention stops the bleeding, and the shock stabilizes. Which finding should the nurse act upon immediately?
a. The blood pH is 7.36.
b. Bowel sounds are hypoactive.
c. Urinary output is 15 mL/hour.
d. Pupils are equally reactive to light.
ANS: C
Because blood is shunted away from the kidneys early in shock to save fluid and provide oxygen to vital organs, the kidneys commonly are injured first. The kidneys can tolerate reduced blood flow for about 1 hour before sustaining permanent damage. Urine output should be monitored for reduction to detect injury. D. Pupils that are equally reactive to light are normal. B. Bowel sounds typically remain hypoactive after surgery. A. Acidosis is expected with shock, and a pH within normal limits is normal.
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