Nokea
Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which of the following patient information indicates that the nurse should consult with the health care provider before administration of the norepinephrine?
- A. The patient's central venous pressure is 3 mm Hg
- B. The patient is receiving low dose dopamine
- C. The patient is in sinus tachycardia at 100-110 beats/minute
- D. The patient has had no urine output since being admitted
Correct Answer: A
Rationale: A low central venous pressure (3 mm Hg) indicates hypovolemia, and fluid resuscitation should be prioritized before administering norepinephrine to avoid exacerbating hypotension. The other findings are consistent with hypovolemic shock and do not contraindicate norepinephrine after adequate fluid replacement.
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The nurse is caring for a patient with septic shock who has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 40°C, and arterial oxygen saturation of 88%. Which of the following interventions should the nurse implement first?
- A. Administer acetaminophen 650 mg via nasogastric tube
- B. Give drotrecogin-?± IV
- C. Administer oxygen via non-rebreather mask
- D. Infuse normal saline 500 mL over 30 minutes
Correct Answer: C
Rationale: Administering oxygen via a non-rebreather mask is the priority to address the patient's low oxygen saturation (88%) and ensure adequate oxygenation in septic shock. Other interventions, such as fluids, drotrecogin-?±, or acetaminophen, are important but secondary to correcting hypoxemia.
The nurse is caring for a patient who is receiving vasopressin to treat septic shock. Which of the following assessments is most important for the nurse to communicate to the health care provider?
- A. The patient's heart rate is 108 beats/minute
- B. The patient is complaining of chest pain
- C. The patient's peripheral pulses are weak
- D. The patient's urine output is 15 ml/hour
Correct Answer: B
Rationale: Chest pain in a patient receiving vasopressin, a potent vasoconstrictor, may indicate decreased coronary artery perfusion, requiring immediate reporting to the provider. The other findings are consistent with septic shock but are less urgent than potential cardiac ischemia.
The nurse is caring for a patient with neurogenic shock that has just arrived in the emergency department after a diving accident. He has a cervical collar in place. Which of the following actions should the nurse take? (Select all that apply.)
- A. Prepare to administer atropine IV
- B. Obtain baseline body temperature
- C. Prepare for intubation and mechanical ventilation
- D. Administer large volumes of lactated Ringer's solution
- E. Administer high-flow oxygen (100%) by non-rebreather mask
Correct Answer: A,B,C,E
Rationale: Neurogenic shock requires atropine for bradycardia, temperature monitoring for poikilothermia, preparation for intubation due to potential respiratory compromise, and high-flow oxygen to support oxygenation. Large volumes of lactated Ringer's are avoided to prevent volume overload, as blood volume is typically normal in neurogenic shock.
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.
The nurse is caring for a patient in the emergency department (ED) with massive trauma and possible spinal cord injury. Which of the following findings by the nurse will help confirm a diagnosis of neurogenic shock?
- A. Cool, clammy skin
- B. Inspiratory crackles
- C. Apical heart rate 48 beats/minute
- D. Temperature 38.4°C (101.1°F)
Correct Answer: C
Rationale: Neurogenic shock is characterized by hypotension and bradycardia due to loss of sympathetic tone, as seen with an apical heart rate of 48 beats/minute. Cool, clammy skin is more typical of hypovolemic or cardiogenic shock, inspiratory crackles suggest pulmonary edema, and fever is not specific to neurogenic shock.