Practice Question
The client is a 24-year-old female who fell while horseback riding.
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Rationale:
💎 Absent urine output indicates decreased renal perfusion due to hypovolemic shock from internal bleeding (likely secondary to liver and splenic lacerations). The kidneys are extremely sensitive to perfusion changes, so no output signals inadequate circulation.
💎 Capillary refill >3 seconds (here 6 seconds) reflects poor peripheral perfusion and decreased cardiac output — a critical sign of progressing shock.
💎 The tachycardia (HR 128) and narrow pulse pressure (90/79) further confirm circulatory compromise and ongoing blood loss.
💎 Despite normal oxygen saturation, tissue perfusion is impaired, emphasizing the need for immediate volume resuscitation and potential transfusion.
💎 Prompt provider notification and implementation of rapid IV fluid and blood replacement are essential to prevent irreversible shock and organ failure.
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This question is from HESI EXIT which contains 102 questions.
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Question Details
- Category: RN Nursing Exam(s)
- Subcategory: HESI-Exit Exam(s)
- Domain: HESI Exit Exam(s)~2024
- Answer Choices: 1