A client is seen following a motor vehicle collision. An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital. The IV line is now infusing at 200 mL/hr. Which assessment finding alerts the nurse to the development of hypovolemic shock?

Question

A client is seen following a motor vehicle collision.  An IV infusion of 1 L 0.9% normal saline solution was administered before arrival at the hospital.  The IV line is now infusing at 200 mL/hr.  Which assessment finding alerts the nurse to the development of hypovolemic shock?

Quizplus · Accepted Answer

Hypovolemic shock most commonly occurs from blood loss but can occur in any condition that reduces intravascular volume. Hypovolemia is classified as either an absolute (eg, hemorrhage, surgery, gastrointestinal bleeding, vomiting, diarrhea) or a relative (eg, pancreatitis, sepsis) fluid loss. Reduced intravascular volume results in decreased venous return, decreased stroke volume and cardiac output, inadequate tissue perfusion, and impaired cellular metabolism. Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include: Change in mental status Tachycardia with thready pulse Cool, clammy skin Oliguria Tachypnea Decreased urine output (<0.5 mL/kg/hr) despite fluid replacement indicates inadequate tissue perfusion to the kidneys and is a manifestation of hypovolemic shock in a client with normal renal function (Option C). (Option A) Jugular venous distension is associated with increased central venous pressure and intravascular volume. Hypovolemic shock is associated with decreased intravascular volume and central venous pressure (<2 mm Hg). (Option B) A mean arterial blood pressure of 70-105 mm Hg is considered normal, and >60 mm Hg is needed for adequate tissue perfusion to vital organs (brain, coronary artery). (Option D) Warm, flushed skin can be an early sign of septic or neurogenic shock but is not associated with hypovolemic shock. Educational objective: Clinical manifestations of hypovolemic shock are associated with inadequate tissue perfusion and include change in mental status; tachypnea; tachycardia with thready pulse; cool, clammy skin; and oliguria.

A Client Is Seen Following a Motor Vehicle Collision