Nokea
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.
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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.
The nurse is caring for a patient in the emergency department (ED) who is in shock of unknown etiology. Which of the following actions should the nurse implement first?
- A. Administer oxygen
- B. Attach a cardiac monitor
- C. Obtain the blood pressure
- D. Check the level of consciousness
Correct Answer: A
Rationale: In shock of unknown etiology, the priority is to ensure adequate oxygenation by administering oxygen first, following the CAB (circulation, airway, breathing) framework. Other actions, such as monitoring, blood pressure, or consciousness checks, follow oxygen administration.
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.
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.
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.