NCLEX PN Practice Questions Practice Question
The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?
Correct Answer: B
Rationale: In assessing for shock, an elevated pulse rate is a significant indicator. A pulse of 100 suggests tachycardia, which is commonly seen in shock as the body attempts to maintain adequate circulation despite reduced blood volume or pressure.
Option A, BP=140/60, indicates a widened pulse pressure, which may not suggest shock and could indicate other conditions. Option C, BP=114/68, shows stable blood pressure and is unlikely to indicate shock. Option D, Pulse=60, indicates bradycardia, which is not typically associated with shock and may suggest other issues. Thus, an increased pulse rate is the most indicative finding of shock.
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