A nurse is assisting the provider to care for trauma patient who has been diagnosed with a hemothorax. Which of the following actions should the nurse perform first to treat this cause of obstructive shock?

Prepare for chest tube insertion

Chart assessment findings

Administer lorazepam

Initiate IV fluid resuscitation

Answer and Explanation

The Correct Answer is A

A) Prepare for chest tube insertion:
The priority treatment for a hemothorax, which is a collection of blood in the pleural space, is to address the loss of intravascular volume and to relieve the pressure on the lungs. The insertion of a chest tube is the first step in draining the blood and restoring proper lung function and ventilation. This intervention directly addresses the cause of obstructive shock (increased pressure on the lungs and impaired cardiac output) by re-expanding the lung and preventing further complications such as respiratory distress or cardiovascular collapse.

B) Chart assessment findings:
While accurate documentation of the patient's condition is important for ongoing care and legal purposes, it is not the priority action in this situation. Immediate treatment to address the hemothorax, such as chest tube insertion, takes precedence over documentation. Charting should be done after stabilizing the patient.

C) Administer lorazepam:
Lorazepam is an anxiolytic medication that might be used for anxiety or agitation, but it is not an immediate priority in this situation. The patient's life-threatening condition (hemothorax) needs to be addressed first, and sedation or anxiety management should be considered once the patient is stabilized and receiving appropriate interventions.

D) Initiate IV fluid resuscitation:
While fluid resuscitation is essential in trauma patients with hypovolemic shock, the primary concern in hemothorax is relieving the intrathoracic pressure by draining the blood from the pleural space. IV fluid resuscitation should be initiated shortly after or simultaneously with the chest tube insertion, but addressing the hemothorax directly is the first priority in treating obstructive shock.

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Correct Answer is A

Explanation

A) Use the 3-second markers to count the number of QRS complexes in 6 seconds and multiply by 10:
The 3-second markers on the ECG strip represent a fixed time interval. By counting the number of QRS complexes in the 6-second interval (i.e., two 3-second markers), you can estimate the heart rate by multiplying the number of QRS complexes by 10. This method is quick and effective for calculating heart rate in an emergency setting, such as in arrhythmias or when time is of the essence.

B) Print a 1-minute ECG strip and count the number of QRS complexes:
While this is another way to assess the heart rate, it is not a quick method, especially in emergency situations. It is more time-consuming because it involves printing out a full strip (or ensuring you have enough data to calculate a full minute). This approach may be useful for detailed analysis but is not optimal for quickly estimating the ventricular rhythm.

C) Calculate the number of small squares between one QRS complex and the next one and divide by 1500:
This method is more complex and is used for calculating the heart rate with a more precise ECG reading. It requires counting the number of small squares between two QRS complexes and dividing by 1500 (the number of small squares in one minute). This method is accurate but not the fastest option for quickly estimating the heart rate during an emergency.

D) Count the number of large squares in the R-R interval and divide by 300:
counting the number of large squares between two R-R intervals and dividing by 300, you get the heart rate. However, this method is less commonly used in emergency situations because it requires more time and may not be as immediate as using the 3-second markers. It is more applicable when doing a detailed analysis of the rhythm.

A. increased cardiac output. B. inadequate tissue perfusion. C. fluid overload or deficit D. vasoconstriction of vasculature.

Correct Answer is B

Explanation

A) Increased cardiac output:
While cardiac output is an important factor in shock management, the primary goal of nursing care is not specifically to increase cardiac output. Shock typically involves inadequate tissue perfusion, which may be caused by a variety of factors including low cardiac output, vasodilation, or fluid imbalance. The focus of nursing care is to restore adequate perfusion to tissues, which may involve improving cardiac output as part of a larger therapeutic strategy.

B) Inadequate tissue perfusion:
The primary goal in the treatment of shock is to restore adequate tissue perfusion, as shock is defined by a failure of the circulatory system to supply sufficient oxygen and nutrients to the body's tissues and organs. Inadequate tissue perfusion can lead to organ dysfunction and, if not addressed, can result in organ failure and death. Nursing interventions are aimed at improving perfusion through fluid resuscitation, vasoactive medications, and other strategies to ensure that oxygen and nutrients are delivered to vital organs.

C) Fluid overload or deficit:
Managing fluid status is crucial in shock, as fluid imbalance (either overload or deficit) can exacerbate the condition. However, fluid overload or deficit is not the primary focus; rather, it is one aspect of managing inadequate tissue perfusion. For example, in hypovolemic shock, the nurse would manage fluid deficit, while in cardiogenic shock, the focus would be on optimizing fluid balance without causing overload.

D) Vasoconstriction of vasculature:
While vasoconstriction can be a compensatory mechanism in certain types of shock (e.g., hypovolemic shock), the primary goal is not to induce vasoconstriction per se. In some cases, vasodilation may occur (as in septic shock), and vasoconstriction could be harmful. The goal is to optimize the vascular tone and perfusion, which may involve vasodilation or vasoconstriction depending on the type of shock.

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A nurse is assisting the provider to care for trauma patient who has been diagnosed with a hemothorax. Which of the following actions should the nurse perform first to treat this cause of obstructive shock?

Nursing Test Bank

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