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 ["A","B","D","E"]
Explanation
These manifestations occur as compensatory mechanisms in response to decreased blood volume and compromised tissue perfusion. The body attempts to compensate for the inadequate circulating volume by increasing heart rate (A) and respiratory rate (B) to enhance oxygen delivery.
D. The decreased systolic blood pressure (D) is a result of decreased cardiac output and vasoconstriction in an attempt to maintain perfusion to vital organs.
E. The decreased urine output (E) is a result of decreased renal perfusion due to decreased blood volume.
C. Decreased pulse rate in (option C) is incorrect because it is not typically seen in the compensatory stage of hypovolemic shock. The body tries to increase heart rate to maintain cardiac output and compensate for the decreased blood volume.
F. Bilateral crackles in (option F) is incorrect because the lung bases are more commonly associated with conditions such as pulmonary edema or fluid overload, rather than the compensatory stage of hypovolemic shock.
It's important to note that the manifestations of shock can vary depending on individual patient factors and the underlying cause of shock. Therefore, a comprehensive assessment and clinical judgment are necessary to fully evaluate the patient's condition.
Correct Answer is D
Explanation
Norepinephrine is a potent vasoconstrictor and inotropic agent commonly used to increase blood pressure in cases of hypotension or shock. However, if the infusion rate is too high, it can lead to excessive vasoconstriction and potentially compromise organ perfusion.
A heart rate of 58 beats/min suggests bradycardia, which can be an indication of excessive vasoconstriction caused by a high dose or rate of norepinephrine infusion. Excessive vasoconstriction can reduce cardiac output and worsen tissue perfusion.
A. Mean arterial pressure is 55 mm Hg in (option A) is incorrect because A mean arterial pressure of 55 mm Hg may be within an acceptable range for a patient receiving norepinephrine infusion, depending on the patient's baseline blood pressure and clinical condition.
B. Systemic vascular resistance (SVR) is elevated in (option B) is incorrect because An elevated SVR indicates increased peripheral vascular resistance and can be a desired effect of norepinephrine infusion to improve blood pressure and perfusion.
C. Pulmonary artery wedge pressure (PAWP) is low in (option C) which is incorrect because A low PAWP may indicate decreased left ventricular preload, which can be a desired effect of norepinephrine infusion to reduce fluid overload in certain clinical conditions.
It is important for the nurse to carefully monitor the patient's hemodynamic parameters, including blood pressure, heart rate, and organ perfusion when titrating norepinephrine infusion to ensure optimal dosing and minimize potential adverse effects. If concerns arise regarding the infusion rate, the healthcare provider should be promptly notified for further evaluation and adjustment of the treatment plan.
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