A patient who is hemorrhaging has pale mucous membranes, blood pressure 92/52 mm Hg, pulse 160 beats/minute, and respirations 30/minute
The patient is receiving IV fluids at 150 mL/hour, has a blood transfusion infusing, and is being provided oxygen via a mask. What should the nurse recognize as the most likely cause of the patient's respiratory rate?
a. Electrolyte imbalances
b. Inadequate tissue perfusion
c. Rapid rate of fluid replacement
d. Reaction to the blood transfusion
ANS: B
When blood pressure falls, the body activates the sympathetic nervous system to increase cardiac output to deliver adequate oxygen to the tissues by causing the heart to beat faster and stronger. Compensatory responses produce the classic signs and symptoms of the initial stage of shock: tachycardia; tachypnea; restlessness; anxiety; and cool, clammy skin with pallor. A. An electrolyte imbalance will not affect the patient's respiratory rate. C. The fluids should provide the body with needed volume and reduce the rapid respiratory rate. D. A blood transfusion reaction would have manifestations other than a rapid respiratory rate.
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Which situation represents a nurse using clinical decision-making skills?
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When preparing to teach a patient about continuous bladder irrigation, the nurse notes that the most frequently used irrigant is
a. sterile isotonic saline. b. an antibiotic solution. c. sterile water. d. heparinized normal saline.
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a. orders b. data c. information d. wisdom
Screening questions for alcohol and drug abuse should be included in the overall assess-ment during the first prenatal visit for all women
The 4 Ps Plus is a screening tool de-signed specifically to identify when there is a need for a more in-depth assessment. The 4 Ps include all except: a. Present b. Partner c. Past d. Pregnancy