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.

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Correct Answer is C

Explanation

The nurse should listen over both lung fields to ensure that air entry is present bilaterally, indicating that the tube is correctly positioned in the trachea. This comes after observing chest movements.

B. Using an end-tidal CO2 monitor to check for placement in the trachea in (option B) is incorrect because End-tidal CO2 monitoring can provide confirmation of correct tube placement in the trachea by detecting exhaled CO2 levels. However, it requires additional equipment and setup, which may not be readily available at the bedside or immediately accessible.
C. Observing the chest for symmetrical movement with ventilation is the initial action after placing an endotracheal tube.
D. Obtaining a portable chest radiograph to check tube placement (option D) is incorrect because Chest radiographs are commonly used to confirm endotracheal tube placement, especially for long-term confirmation or if there are concerns about placement. However, obtaining a portable chest radiograph may involve delays and is not the initial action to be taken for immediate verification.
Therefore, the best initial action by the nurse to verify the correct placement of an endotracheal tube (ET) after insertion is to auscultate for the presence of bilateral breath sounds.

A. Nitroglycerine (Tridil). B. Atenolol (Tenormin). C. Dobutamine (Dobutrex). D. Norepinephrine (Levophed).

Correct Answer is D

Explanation

Norepinephrine is a vasopressor medication commonly used in the management of septic shock. It acts as a potent vasoconstrictor to increase systemic vascular resistance and improve blood pressure. By constricting blood vessels, norepinephrine helps restore tissue perfusion and improve organ function.
A. Nitroglycerine (Tridil) in (option A) is incorrect because: Nitroglycerine is a vasodilator and would further lower blood pressure. It is not suitable for a patient with septic shock who already has low blood pressure.
B. Atenolol (Tenormin) in (option B) is incorrect because: Atenolol is a beta-blocker and would further decrease heart rate and blood pressure. It is not appropriate for a patient in septic shock who requires intervention to increase blood pressure.
C. Dobutamine (Dobutrex) in (option C) is incorrect because: Dobutamine is an inotropic medication used to increase cardiac output. While it can be helpful in certain types of shock, such as cardiogenic shock, it is not the first-line choice for septic shock when there is inadequate blood pressure response.

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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?

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Naxlex Comprehensive Predictor Exams

To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to:

Correct Answer is C

Explanation

A 66-year-old female patient in septic shock has received fluid resuscitation, but their mean arterial pressure (MAP) is 52 mmHg. The nurse anticipates the administration of which one of the following?

Correct Answer is D

Explanation

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