hard · NCLEX-RN Physiological Adaptation

The nurse is reviewing the 'Five Steps of Clinical Judgment' for a client in shock. Which actions correspond to the 'Analyze Mechanism' step? Select all that apply.

  1. Ranking the consequence of delaying treatment for septic shock
  2. Starting a 1-liter fluid bolus as ordered
  3. Identifying that cool, clammy skin with flat neck veins suggests hypovolemia
  4. Reassessing the MAP ten minutes after a medication change
  5. Differentiating if hypotension is caused by pump failure or volume loss

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