A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
obtain the blood pressure.
Check the level of consciousness.
administer oxygen.
obtain a 12-lead electrocardiogram (ECG).
The Correct Answer is B
Assessing the patient's level of consciousness is a critical initial step in evaluating a patient with shock. Altered mental status or decreased level of consciousness can be indicative of inadequate cerebral perfusion and may require immediate interventions to address compromised brain function and ensure patient safety.
While all the options mentioned are important in the assessment and management of a patient in shock, checking the level of consciousness takes priority as it provides essential information about the patient's neurological status and helps guide further interventions.
A. Obtaining the blood pressure in (option A) is incorrect because Assessing blood pressure is crucial in evaluating a patient in shock, but it can be done in conjunction with checking the level of consciousness and other vital signs.
C. Administering oxygen in (option C) is incorrect because: Administering oxygen is important in managing shock, as tissue hypoxia is a key concern. However, it can be done simultaneously with assessing the level of consciousness and initiating other interventions.
D. Obtaining a 12-lead electrocardiogram (ECG) in (option D) is incorrect because While an ECG may provide valuable information about the patient's cardiac function, it is not the first priority in a patient with shock of unknown etiology. Assessing the level of consciousness and vital signs takes precedence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["9000"]
Explanation
4 mL × body weight in kg × percentage of burn = total fluid volume for the first 24 hours Then, divide the total fluid volume by 2 to determine the fluid volume for the first 8 hours.
In this case, the patient weighs 90 kg and has a 50% burn injury.
4 mL × 90 kg × 50% = 18,000 mL (total fluid volume for 24 hours)
18,000 mL / 2 = 9,000 mL (fluid volume for the first 8 hours)
Therefore, the nurse would infuse the intravenous fluid resuscitation at a rate of 9,000 mL over the first 8 hours.
Correct Answer is B
Explanation
Fresh frozen plasma (FFP) is a blood product that contains various clotting factors, including factors II, V, VII, VIII, IX, X, XI, and XIII. These clotting factors are essential for the normal coagulation process. In patients with shock, coagulation abnormalities can occur, and administration of FFP can help replenish the deficient clotting factors and restore proper coagulation function.
The other options mentioned are not the primary components replaced by fresh frozen plasma:
A. Red blood cells are in (option A) is incorrect because Red blood cells carry oxygen and are typically replaced by packed red blood cell transfusions in cases of significant blood loss or anemia. Fresh frozen plasma does not contain a significant amount of red blood cells.
C. Platelets in (option C) is incorrect because: Platelets play a role in blood clotting and are typically replaced by platelet transfusions in cases of thrombocytopenia or platelet dysfunction. Fresh frozen plasma may contain a small number of platelets but is not the primary source for platelet replacement.
D. White blood cells in (option D) is incorrect because White blood cells are part of the immune system and are not typically replaced using fresh frozen plasma. Fresh frozen plasma does not contain a significant amount of white blood cells.
Therefore, fresh frozen plasma is primarily administered to patients in shock to replace clotting factors and help restore proper coagulation function.
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