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A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin, tachycardia, and hypotension. Which of the following prescribed interventions should the nurse implement first?
- A. Place the patient on continuous cardiac monitor
- B. Draw blood to type and cross-match for transfusions
- C. Insert two 14-gauge IV catheters
- D. Administer oxygen at 100% per non-rebreather mask
Correct Answer: D
Rationale: Administering oxygen at 100% via a non-rebreather mask is the first priority to ensure adequate oxygenation and support airway and breathing in a patient with hypovolemic shock from trauma. Cardiac monitoring, IV insertion, and blood draws follow to support circulation.
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Which of the following interventions should the nurse include in the plan of care for a patient experiencing cardiogenic shock?
- A. Avoid elevating head of bed
- B. Check temperature every 2 hours
- C. Monitor breath sounds frequently
- D. Assess skin for flushing and itching
Correct Answer: C
Rationale: Frequent monitoring of breath sounds is critical in cardiogenic shock to detect pulmonary congestion and dyspnea, which are hallmark symptoms. Elevating the head of the bed reduces dyspnea, temperature monitoring is less specific, and flushing or itching is not typical of cardiogenic shock.
Which of the following assessments should the nurse make to evaluate the effectiveness of omeprazole administration to a patient with systemic inflammatory response syndrome (SIRS)?
- A. Auscultate bowel sounds
- B. Ask the patient about nausea
- C. Monitor stools for occult blood
- D. Check for abdominal distention
Correct Answer: C
Rationale: Omeprazole, a proton pump inhibitor, is given to reduce the risk of stress ulcers in critically ill patients with SIRS. Monitoring stools for occult blood directly assesses the effectiveness of this intervention by checking for gastrointestinal bleeding. The other assessments are relevant but do not specifically evaluate omeprazole's effectiveness.
During change-of-shift report, the nurse learns that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 3 days. Which of the following findings is most important for the nurse to report to the health care provider?
- A. Decreased bowel sounds
- B. Apical pulse 110 beats/minute
- C. Pale, cool, and dry extremities
- D. New onset of confusion and agitation
Correct Answer: D
Rationale: New onset confusion and agitation indicate progression to the progressive stage of hypovolemic shock, signaling inadequate cerebral perfusion and the need for immediate intervention. The other findings are consistent with compensatory shock but are less urgent.
Which of the following information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)?
- A. The patient's serum creatinine level is elevated
- B. The patient complains of intermittent chest pressure
- C. The patient has crackles throughout both lung fields
- D. The patient's extremities are cool and pulses are weak
Correct Answer: A
Rationale: An elevated serum creatinine level indicates renal failure, a sign of MODS in the context of cardiogenic shock. Crackles, chest pressure, and cool extremities are consistent with cardiogenic shock but do not specifically indicate MODS.
The health care provider prescribes the following actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions?
- A. Obtain blood and urine cultures
- B. Give vancomycin 1 g IV
- C. Infuse vasopressin 0.01 units/minute
- D. Administer normal saline 1000 mL over 30 minutes
- E. Titrate oxygen administration to keep O2 saturation >95%
Correct Answer: E,D,C,A,B
Rationale: The priority is to improve oxygenation (titrate oxygen), followed by fluid resuscitation (normal saline), vasopressor administration (vasopressin), obtaining cultures, and finally administering antibiotics (vancomycin) to ensure timely treatment while confirming the infection source.