A client experiencing trauma begins to show early signs of hypovolemic shock. Before notifying the medical team, what should the nurse do first?
1. Raise the head of the bed.
2. Turn the client to Sims' position.
3. Establish responsiveness.
4. Place the client on 12-15 L/minute of oxygen.
Answer: 4
1. The immediate need of the client who is experiencing early shock is oxygen to prevent damage to the cells. Raising the head of the bed is not the priority intervention.
2. Administering oxygen takes precedence over positioning.
3. The client in early shock is usually conscious but restless.
4. Because of the blood loss, the cells of the body are receiving little oxygen. The first action of the nurse is to start the client on oxygen to prevent cell and tissue damage.
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