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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.
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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 in pulmonary edema as result of cardiogenic shock has the following vital signs: BP 86/50, pulse 126, respirations 30. Which of the following actions should the nurse anticipate implementing?
- A. Infusion of 5% human albumin
- B. Administration of furosemide IV
- C. Titration of an epinephrine drip
- D. Administration of hydrocortisone
Correct Answer: B
Rationale: Furosemide, a diuretic, is appropriate to reduce fluid overload in pulmonary edema due to cardiogenic shock, helping to alleviate symptoms like dyspnea. Albumin and normal saline would worsen fluid overload, epinephrine would increase myocardial oxygen demand, and hydrocortisone is used for septic or anaphylactic shock, not cardiogenic shock.
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.
Which of the following findings is the best indicator that the fluid resuscitation for a patient with hypovolemic shock has been successful?
- A. Hemoglobin is within normal limits
- B. Urine output is 60 mL over the last hour
- C. Pulmonary artery occlusive pressure (PAOP) is normal
- D. Mean arterial pressure (MAP) is 65 mm Hg
Correct Answer: B
Rationale: Adequate urine output (e.g., 60 mL/hour) is the best indicator of successful fluid resuscitation in hypovolemic shock, as it reflects restored renal perfusion and end-organ function. Hemoglobin, PAOP, and MAP are useful but less specific for confirming adequate organ perfusion.
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.