Nokea
The nurse is caring for a patient with shock whose hemodynamic monitoring indicates BP 92/54, pulse 64, and an elevated pulmonary artery wedge pressure. Which of the following prescribed interventions should the nurse question?
- A. Infuse normal saline at 250 ml/hour
- B. Keep head of bed elevated to 30 degrees
- C. Give nitroglycerin unless systolic BP <90 mm Hg
- D. Administer dobutamine to keep systolic BP >90 mm Hg
Correct Answer: A
Rationale: The patient's elevated pulmonary artery wedge pressure indicates volume excess, and infusing normal saline at 250 ml/hour could worsen this condition, potentially leading to pulmonary edema. The other actions are appropriate to support cardiac function and manage shock.
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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 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.
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.
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 who has septic shock. Which of the following assessment findings is most important for the nurse to report to the health care provider?
- A. BP 92/56 mm Hg
- B. Skin cool and clammy
- C. Apical pulse 118 beats/minute
- D. Arterial oxygen saturation 91%
Correct Answer: B
Rationale: Cool, clammy skin in septic shock indicates progression from the early warm, flushed stage to a more severe stage with poor perfusion, requiring urgent intervention. The other findings are consistent with septic shock but do not indicate deterioration as critically as cool, clammy skin.