Nokea
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.
You may also like to solve these questions
The new RN is being mentored while caring for a patient with neurogenic shock. Which of the following actions by the new RN indicates a need for further teaching?
- A. Keeping the room temperature at 75°F to prevent hypothermia
- B. Checking the heart rate every 1-2 hours
- C. Preparing to administer prescribed IV atropine
- D. Increasing the nitroprusside infusion rate for a patient with a high SVR
Correct Answer: D
Rationale: Increasing the nitroprusside infusion rate is inappropriate for neurogenic shock, as it is a vasodilator and could worsen hypotension. The other actionsâ??maintaining warm room temperature, monitoring heart rate, and preparing atropineâ??are appropriate for managing neurogenic shock, which involves bradycardia and hypothermia risk.
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.
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.
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.
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.