Difficulty: Medium
Average Score: 93%
Full-length
The client is admitted to the intensive care unit following a coronary artery bypass graft. The nurse checks the vital signs and notes a heart rate of 120 beats per minute, blood pressure of 70/40, and respiration of 32 breaths per minute. The nurse suspects hypovolemic shock. Which assessment tools would contribute to a diagnosis of hypovolemic shock?
Correct answer
A, B, D
Rationale
Hypovolemic shock involves low blood volume, reflected by low hemoglobin (5 g, A), low central venous pressure (2 mmHg, B), and low hematocrit (22%, D). Normal pulmonary artery wedge pressure (16 mmHg, C) suggests no left heart failure. Elevated troponin (E) indicates myocardial damage, not volume status.