A 27-year-old male patient who has been involved in a motor vehicle crash is admitted to the emergency department with cool, clammy skin, tachypnoea, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

Place the patient on a continuous cardiac monitor.

Administer oxygen at 100% per non-rebreather mask.

Insert two 14-gauge IV catheters.

Draw blood to type and crossmatch for transfusions.

Answer and Explanation

The Correct Answer is B

In this scenario, the patient's signs and symptoms suggest a state of shock, which can be caused by various factors, such as hypovolemia, cardiac dysfunction, or systemic vasodilation. The first priority in managing a patient in shock is to ensure adequate oxygenation and tissue perfusion. Administering oxygen at 100% per non-rebreather mask helps improve oxygen delivery to the tissues and supports vital organ function.
A. Placing the patient on a continuous cardiac monitor in (option A) is incorrect because it is an important step to monitor the patient's heart rhythm and identify any abnormalities. However, providing oxygen should take priority to address the potential hypoxemia and tissue hypoperfusion.
C. Inserting two 14-gauge IV catheters in (option C) is incorrect because it is crucial for establishing large-bore access for fluid resuscitation and medication administration. While it is an important step, addressing oxygenation takes precedence.
D. Drawing blood to type and crossmatch for transfusions in (option D) is incorrect because it is an important step in managing a patient in shock who may require blood products. However, ensuring adequate oxygenation through oxygen administration is the immediate priority.
Therefore, the nurse should act first on the order to administer oxygen at 100% per non-rebreather mask to support the patient's oxygenation and tissue perfusion.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Shock is a state of inadequate tissue perfusion, resulting in compromised oxygen and nutrient delivery to cells and impaired cellular metabolism. Regardless of the specific cause or type of shock (e.g., hypovolemic, cardiogenic, distributive), the underlying problem is the failure to supply sufficient oxygen and nutrients to the body's tissues. This inadequate tissue perfusion can lead to cellular dysfunction, organ failure, and ultimately, life-threatening consequences.
A. Inefficient metabolism resulting from inadequate nutrition in (option A) is incorrect because While inadequate nutrition can contribute to the overall health status and resilience of an individual, it is not the central mechanism underlying all shock states.
C. Vasoconstriction and reflexive vasodilation due to circulating mediators in (option C) is incorrect because Vasoconstriction and vasodilation are physiological responses that can occur in various types of shock, but they are not the fundamental common denominator. Inadequate tissue perfusion remains the core issue.
D. Hypovolemia resulting from blood loss in (option D) is incorrect because Hypovolemia, which refers to decreased blood volume, is one potential cause of shock, specifically hypovolemic shock. However, other types of shock, such as cardiogenic or distributive shock, may not be primarily characterized by hypovolemia.
Therefore, the common denominator of all shock states is inadequate tissue perfusion, resulting in impaired cellular metabolism.

A. Cooling baths B. Blood transfusion C. 30 ml/kg of Lactated Ringers (LR) D. NPO Status

Correct Answer is C

Explanation

The sepsis resuscitation bundle typically includes the administration of intravenous fluids to restore adequate perfusion and address hypovolemia. The initial fluid of choice is often the crystalloid solution, such as Lactated Ringers (LR), and the recommended initial fluid bolus is 30 ml/kg. This intervention aims to optimize intravascular volume and improve tissue perfusion.

A. Cooling baths in (option A) is incorrect because they may be used in the management of hyperthermia or fever, but they are not specific interventions in the sepsis resuscitation bundle.

B. Blood transfusion in (option B) is incorrect it may be necessary in certain cases of sepsis, such as severe anemia or hypovolemia, but it is not a routine intervention in the sepsis resuscitation bundle based solely on the provided information.

D. NPO status (nothing by mouth) in (option D) is incorrect because it is not a specific intervention in the sepsis resuscitation bundle. It may be indicated in certain cases, such as when surgery is required or if there is a risk of aspiration, but it does not directly address the sepsis-related variables mentioned.

It is important to note that the specific management of sepsis may vary based on the patient's individual condition, clinical presentation, and healthcare provider's orders.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A 27-year-old male patient who has been involved in a motor vehicle crash is admitted to the emergency department with cool, clammy skin, tachypnoea, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The common denominator of all shock states is which one of the following?

Correct Answer is B

Explanation

A 30-year-old female patient is admitted to the emergency department with two systemic inflammatory response syndrome variables: temperature of 100.2°F (35°C) and high blood sugar. Which intervention from the sepsis resuscitation bundle does the nurse initiate?

Correct Answer is C

Explanation

The cardiac ICU nurse is assessing a patient who is in cardiogenic shock. Which hemodynamic manifestations and/or signs and symptoms do the nurse expect? Select all that apply.

The emergency department nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective by finding which one of the following?

A 40-year-old female patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on which one of the following?

Which action should the nurse take when the low-pressure alarm sounds for a patient who has an arterial line in the right radial artery?

Ordered: Dopamine2mcg/kg/min In Stock: 200mg in 250mL Saline Patients weight: 60kg What rate would you set the pump to deliver the ordered medication? (Document to the nearest whole number)

Four hours after mechanical ventilation is initiated for a patient with a suspected drug overdose, the patient's arterial blood gas (ABG) results include a pH of 7.50, Pa0 2 of 80 mm Hg. PaCO2 of 29 mmHg, and HCO3 of 23 mEq/L (23 mmo/L). The nurse will anticipate the need to:

Following surgery, a patient's central venous pressure (CVP) monitor indicates high pressures. Which action will the nurse anticipate taking?

The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment information indicates that the infusion rate may be too high?