Nokea
Which of the following assessments is most important for the nurse to make in order to evaluate whether treatment of a patient with anaphylactic shock has been effective?
- A. Pulse rate
- B. Orientation
- C. Blood pressure
- D. Oxygen saturation
Correct Answer: D
Rationale: Oxygen saturation is the most critical assessment in anaphylactic shock due to the risk of airway edema affecting breathing. Improvements in pulse rate, orientation, and blood pressure are expected but are secondary to ensuring adequate oxygenation.
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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 health care provider prescribes the following actions for a patient who has possible septic shock with a BP of 70/42 mm Hg and oxygen saturation of 90%. In which order will the nurse implement the actions?
- A. Obtain blood and urine cultures
- B. Give vancomycin 1 g IV
- C. Infuse vasopressin 0.01 units/minute
- D. Administer normal saline 1000 mL over 30 minutes
- E. Titrate oxygen administration to keep O2 saturation >95%
Correct Answer: E,D,C,A,B
Rationale: The priority is to improve oxygenation (titrate oxygen), followed by fluid resuscitation (normal saline), vasopressor administration (vasopressin), obtaining cultures, and finally administering antibiotics (vancomycin) to ensure timely treatment while confirming the infection source.
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.
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.
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.