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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.
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After receiving 1000 mL of normal saline, the central venous pressure for a patient who has septic shock is 10 mm Hg, but the blood pressure is still 82/40 mm Hg. Which of the following prescribed medications should the nurse administer?
- A. Nitroglycerin
- B. Drotrecogin-?±
- C. Norepinephrine
- D. Sodium nitroprusside
Correct Answer: C
Rationale: Norepinephrine, a vasopressor, is appropriate to increase systemic vascular resistance and improve blood pressure when fluid resuscitation is insufficient in septic shock. Nitroglycerin and nitroprusside are vasodilators and would worsen hypotension, while drotrecogin-?± addresses inflammation but not blood pressure directly.
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.
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 nurse is caring for a patient with shock whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which of the following prescribed interventions should the nurse question?
- A. Infuse normal saline at 250 ml/hour
- B. Keep head of bed elevated to 30 degrees
- C. Give nitroglycerin unless systolic BP <90 mm Hg
- D. Administer dobutamine to keep systolic BP >90 mm Hg
Correct Answer: A
Rationale: The patient's elevated pulmonary artery wedge pressure indicates volume excess, and infusing normal saline at 250 ml/hour could worsen this condition, potentially leading to pulmonary edema. The other actions are appropriate to support cardiac function and manage shock.
The nurse is caring for a patient who has septic shock. Which of the following assessment findings is most important for the nurse to report to the health care provider?
- A. BP 92/56 mm Hg
- B. Skin cool and clammy
- C. Apical pulse 118 beats/minute
- D. Arterial oxygen saturation 91%
Correct Answer: B
Rationale: Cool, clammy skin in septic shock indicates progression from the early warm, flushed stage to a more severe stage with poor perfusion, requiring urgent intervention. The other findings are consistent with septic shock but do not indicate deterioration as critically as cool, clammy skin.