The nurse is reviewing data for a patient experiencing shock. Based on these data, the nurse recognizes that the patient is in which stage of shock?
1. compensatory
2. early, reversible
3. progressive
4. refractory
Correct Answer: 3
In compensatory shock, the blood loss is 750 mL, with up to 15% blood volume loss. Other indicators are normal or increased; the patient is only slightly anxious. In early reversible shock there is a blood loss of 750–1500 mL, 15%–30% blood volume loss, heart rate >100, blood pressure normal, pulse pressure decreased, capillary refill and respiratory rate slightly increased, urine output 20–30 mL/h. The patient is mildly anxious to agitated. The manifestations in progressive shock are: blood loss of 1500–2000 mL, 30%–40% blood volume loss, heart rate >120, blood pressure and pulse pressure decreased, capillary refill increased over normal, moderate tachypnea, urinary output below normal, and mental status altered. In refractory shock, the patient's condition has deteriorated markedly, with over 2,000 mL blood loss and >40% loss of blood volume.
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