Nokea
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.
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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.
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.
Which of the following information obtained by the nurse when caring for a patient who has cardiogenic shock indicates that the patient may be developing multiple organ dysfunction syndrome (MODS)?
- A. The patient's serum creatinine level is elevated
- B. The patient complains of intermittent chest pressure
- C. The patient has crackles throughout both lung fields
- D. The patient's extremities are cool and pulses are weak
Correct Answer: A
Rationale: An elevated serum creatinine level indicates renal failure, a sign of MODS in the context of cardiogenic shock. Crackles, chest pressure, and cool extremities are consistent with cardiogenic shock but do not specifically indicate MODS.
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.
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.