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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This method, known as the 6-second method, involves counting the number of QRS complexes in a 6-second interval on the electrocardiogram (ECG) strip and then multiplying that number by 10 to calculate the heart rate per minute. The advantage of this method is that it provides a relatively quick estimate of the heart rate.
A. Printing a 1-minute ECG strip and counting the number of QRS complexes in (option A) is incorrect because it can be time-consuming and may not be practical in situations where a quick estimate is needed.
B. Calculating the number of small squares between one QRS complex and the next and dividing into 1500 in (option B) is incorrect because it is a method used to calculate heart rate, known as the "1500 method," but it is not as quick as the 6-second method and requires more time and measurement precision.
D. Counting the number of large squares in the R-R interval and dividing by 300 is another method used to calculate heart rate, known as the "300 method," but it is also less quick and less accurate for assessing heart rate in patients with regular rhythms.
It's important to note that if the heart rhythm is irregular, these methods may not provide an accurate estimate of the heart rate, and a longer monitoring period or a different approach may be necessary.
Correct Answer is C
Explanation
Septic shock is characterized by inadequate tissue perfusion and hypotension, which can lead to organ dysfunction and failure. The administration of intravenous fluids, such as a normal saline bolus, is the initial priority in the management of septic shock to restore intravascular volume and improve perfusion.
A. Draw an arterial blood gas (ABG) in (option A) is incorrect because: ABG may be ordered to assess the patient's acid-base status and oxygenation, but addressing hypotension and restoring perfusion through fluid administration takes priority.
B. Start insulin drip to maintain blood glucose at 150 mg/dl or lower in (option B) is incorrect because: Hyperglycaemia is commonly observed in critically ill patients, including those with septic shock. While controlling blood glucose is important, it is not the immediate priority compared to addressing hypotension and restoring intravascular volume.
D. Titrate norepinephrine (Levophed) to keep mean arterial pressure (MAP) greater than 65 mm Hg in (option D) is incorrect because: Norepinephrine is a vasopressor medication used to increase blood pressure and perfusion in septic shock. While it may be necessary for the management of septic shock, fluid resuscitation should be initiated first to optimize intravascular volume before starting vasopressors.
Therefore, the first order that the nurse should accomplish in this scenario is to give a normal saline bolus IV of 30 mL/kg to address the hypotension and restore intravascular volume.
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