A nurse is caring for a client in the emergency department (ED).

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

A. In a patient receiving a dobutamine infusion, which is a vasopressor medication used to increase cardiac output, a cool and pale IV infusion site could indicate inadequate perfusion despite treatment. This finding requires immediate action to assess the patient's hemodynamic status and ensure adequate tissue perfusion.

B. Warm and dry extremities are typically indicative of adequate tissue perfusion. In neurogenic shock, vasodilation can lead to warm extremities due to decreased systemic vascular resistance. While this finding may be expected in neurogenic shock, it does not necessarily indicate a need for immediate action if other parameters are stable.

C. Decreased urine output can be indicative of inadequate renal perfusion and impaired kidney function. In a patient with neurogenic shock, maintaining adequate renal perfusion is crucial to prevent acute kidney injury. While decreased urine output warrants close monitoring and intervention, it may not require immediate action unless other signs of worsening perfusion are present.

D. A heart rate of 58 beats/min may be within the normal range for some patients, especially those who are receiving dobutamine, which can have a chronotropic effect. However, in the context of neurogenic shock, bradycardia may indicate a compensatory response to hypotension and decreased tissue perfusion. While bradycardia alone may not always require immediate action, it should prompt further assessment of the patient's hemodynamic status and response to treatment.

B. This is a reasonable action given the client's respiratory rate and potential hypoxemia resulting from the sucking chest wound. Providing supplemental oxygen can help improve oxygenation and support the client's respiratory effort. However, it doesn't directly address the underlying cause of the shock.

A. In this scenario, the client's vital signs indicate signs of shock, which could be due to significant blood loss from the sucking chest wound. While inserting a central line may be necessary for administering fluids and medications rapidly, it's not the immediate priority in this situation. Stabilizing the client's condition takes precedence.

C. Elevating the foot of the bed to a 90° angle is not appropriate in this situation. This position can further decrease venous return to the heart, potentially exacerbating the client's hypotension and shock. It's crucial to maintain a neutral or slightly elevated position to optimize venous return.

D. While it's important to assess the wound and monitor for any changes, removing the dressing on a sucking chest wound without appropriate precautions can worsen the client's condition. The dressing helps to maintain a seal over the wound, preventing further air from entering the pleural space and worsening the tension pneumothorax. Removing the dressing should be done cautiously and preferably by a healthcare provider trained in managing chest trauma.