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?

Cool, clammy skin.

BP of 82/40 mm Hg.

Heart rate of 48 beats/min.

Shortness of breath.

Answer and Explanation

The Correct Answer is C

Neurogenic shock is a type of distributive shock that occurs due to the loss of sympathetic nervous system tone after a spinal cord injury or other traumatic brain injuries. This loss of sympathetic tone leads to vasodilation and decreased systemic vascular resistance, resulting in inadequate perfusion to vital organs.
One of the hallmark signs of neurogenic shock is bradycardia (a heart rate less than 60 beats/min) due to the unopposed parasympathetic activity. The parasympathetic system becomes dominant when sympathetic activity is impaired. Therefore, a heart rate of 48 beats/min in this patient suggests the possibility of neurogenic shock.
A. Cool, clammy skin in (option A) is incorrect because Cool, clammy skin is a characteristic of hypovolemic shock, where reduced blood volume leads to vasoconstriction to redirect blood flow to vital organs.
B. BP of 82/40 mm Hg in (option B) is incorrect because: Hypotension is a common finding in both neurogenic shock and hypovolemic shock. A low blood pressure reading alone does not specifically indicate neurogenic shock.
D. Shortness of breath in (option D) is incorrect because Shortness of breath is not specific to neurogenic shock but can occur in various types of shock, including hypovolemic shock. It may result from inadequate oxygenation or impaired respiratory function due to the underlying condition or associated injuries.
Therefore, the heart rate of 48 beats/min suggests the possibility of neurogenic shock in addition to hypovolemic shock in this patient.

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Correct Answer is C

Explanation

Heart rate: 72 beats per minute Stroke volume: 90 mL/contraction

Cardiac output = Heart rate × Stroke volume

Cardiac output = 72 beats/minute × 90 mL/contraction

To simplify the calculation, you can convert the units:

72 beats/minute × 90 mL/contraction = (72 × 90) beats/minute × mL/contraction

Now, perform the multiplication:

72 × 90 = 6,480

Therefore, the cardiac output is 6,480 mL per minute.

The correct answer is:

C. 6,480 mL

A. Stop and ventilate the patient with 100% oxygen. B. Check the patient's potassium level C. Give prescribed PRN antidysrhythmic medications. D. Decrease the suction pressure to 80 mm Hg.

Correct Answer is A

Explanation

Premature ventricular contractions (PVCs) are abnormal heart rhythms originating from the ventricles. They can be triggered by various factors, including irritation or stimulation of the airway during suctioning.
In this situation, the priority is to ensure adequate oxygenation and ventilation for the patient. Stopping the suctioning procedure and providing ventilatory support with 100% oxygen helps maintain oxygen levels and minimizes further cardiac dysrhythmias.
B. Check the patient's potassium level in (option B) is incorrect because While electrolyte imbalances, including low potassium levels (hypokalemia), can contribute to cardiac dysrhythmias, checking the potassium level is not the immediate priority when PVCs occur during suctioning.
C. Give prescribed PRN antidysrhythmic medications in (option C) is incorrect because: Administering antidysrhythmic medications without further assessment or evaluation may not be appropriate in this situation.
D. Decrease the suction pressure to 80 mm Hg in (option D) is incorrect because: While adjusting suction pressure may help prevent further irritation, it is not the initial priority when PVCs are present during suctioning.
E. Documenting the dysrhythmia in the patient's chart in (option E) is incorrect because: Documentation is important but should not be the initial action when a patient experiences PVCs during suctioning. Patient safety and immediate intervention take precedence.
Therefore, when PVCs occur during suctioning, the nurse should stop the procedure, provide ventilatory support with 100% oxygen, and assess the patient's response to intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is the cardiac output of a patient whose heart rate is 72 beats per minute with a stroke volume of 90 mL/contraction?

Correct Answer is C

Explanation

Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which action by the nurse is best?

Correct Answer is A

Explanation

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