Nokea
The emergency department (ED) receives notification that a patient who has just been in an automobile accident is being transported to your facility with anticipated arrival in 1 minute. Which of the following should the nurse obtain in preparation for the patient's arrival?
- A. 500 mL of 5% albumin
- B. Lactated Ringer's solution
- C. Two 14-gauge IV catheters
- D. Dopamine infusion
Correct Answer: C
Rationale: Two large-bore (14-gauge) IV catheters are essential for rapid fluid resuscitation in a trauma patient to prevent or treat hypovolemic shock. Crystalloids like normal saline are preferred initially over colloids like albumin. Lactated Ringer's should be used cautiously, and vasopressors like dopamine are not first-line for hypovolemic shock.
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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 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.
Which of the following interventions should the nurse implement first when a patient in the emergency department develops anaphylactic shock?
- A. Administer normal saline 500 mL IV
- B. Insert a second IV catheter
- C. Administer epinephrine 0.3 mg intramuscularly
- D. Start a dopamine infusion at 5 mcg/kg/minute
Correct Answer: C
Rationale: Epinephrine is the first-line treatment for anaphylactic shock, as it rapidly reverses vasodilation, bronchoconstriction, and histamine effects. Fluid resuscitation, additional IV access, and vasopressors like dopamine are secondary actions after epinephrine administration.
The nurse is assessing a patient who is receiving a nitroprusside infusion to treat cardiogenic shock. Which of the following findings indicates that the medication is effective?
- A. No heart murmur is audible
- B. Skin is warm and dry
- C. Troponin level is decreased
- D. Blood pressure is 90/40 mm Hg
Correct Answer: B
Rationale: Warm, dry skin indicates improved tissue perfusion, a sign that nitroprusside, a vasodilator, is effective in reducing afterload and improving cardiac output in cardiogenic shock. Low blood pressure, absence of a heart murmur, or decreased troponin levels are not specific indicators of nitroprusside'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.