Nokea
The nurse is caring for a patient with neurogenic shock who is receiving a phenylephrine infusion through a left forearm IV. Which of the following assessment information obtained by the nurse indicates a need for immediate action?
- A. The patient's IV infusion site is cool and pale
- B. The patient has warm, dry skin on the extremities
- C. The patient has an apical pulse rate of 58 beats/minute
- D. The patient's urine output has been 20 mL over the last hour
Correct Answer: A
Rationale: Coolness and pallor at the IV site suggest extravasation of phenylephrine, a potent vasoconstrictor, which can cause tissue damage and requires immediate action to stop the infusion and notify the provider. The other findings are consistent with neurogenic shock but do not require immediate intervention.
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A patient who has been involved in a motor vehicle crash is admitted to the emergency department (ED) with cool, clammy skin, tachycardia, and hypotension. Which of the following prescribed interventions should the nurse implement first?
- A. Place the patient on continuous cardiac monitor
- B. Draw blood to type and cross-match for transfusions
- C. Insert two 14-gauge IV catheters
- D. Administer oxygen at 100% per non-rebreather mask
Correct Answer: D
Rationale: Administering oxygen at 100% via a non-rebreather mask is the first priority to ensure adequate oxygenation and support airway and breathing in a patient with hypovolemic shock from trauma. Cardiac monitoring, IV insertion, and blood draws follow to support circulation.
The nurse is caring for a patient with septic shock who has had a urine output of 20 ml/hour for the past 3 hours. The pulse rate is 120 and the central venous pressure and pulmonary artery wedge pressure are low. Which of the following orders by the health care provider should the nurse question?
- A. Administer furosemide 40 mg IV
- B. Increase normal saline infusion to 150 ml/hour
- C. Administer hydrocortisone 100 mg IV
- D. Administer dopamine 5 mcg/kg/minute IV
Correct Answer: A
Rationale: Furosemide will lower the filling pressures and renal perfusion further for the patient with septic shock, who already has low central venous pressure and pulmonary artery wedge pressure, indicating hypovolemia. The other orders are appropriate to improve perfusion and manage septic shock.
Which of the following interventions should the nurse include in the plan of care for a patient experiencing cardiogenic shock?
- A. Avoid elevating head of bed
- B. Check temperature every 2 hours
- C. Monitor breath sounds frequently
- D. Assess skin for flushing and itching
Correct Answer: C
Rationale: Frequent monitoring of breath sounds is critical in cardiogenic shock to detect pulmonary congestion and dyspnea, which are hallmark symptoms. Elevating the head of the bed reduces dyspnea, temperature monitoring is less specific, and flushing or itching is not typical of cardiogenic shock.
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.
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.