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).

Answer and Explanation

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.

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Correct Answer is B

Explanation

Lactate is a by-product of anaerobic metabolism that accumulates when there is insufficient oxygen supply to meet cellular metabolic demands. In the context of severe tissue hypoxia, such as in septic shock, the body may resort to anaerobic metabolism, leading to increased lactate production and elevated lactate levels in the blood.
Elevated lactate levels, typically above 4.0 mmol/L, are indicative of tissue hypoxia and inadequate oxygenation at the cellular level. Higher lactate levels, such as 9.0 mmol/L, suggest more severe tissue hypoxia and increased anaerobic metabolism.
A. Partial thromboplastin time (PTT) 64 seconds in (option A) is incorrect because: PTT is a laboratory test that evaluates the intrinsic pathway of the coagulation cascade. While coagulation abnormalities may occur in septic shock, PTT alone does not specifically indicate severe tissue hypoxia.
C. Potassium 2.8 mEq/L (2.8 mmol/L) (option C) is incorrect because Low potassium levels (hypokalemia) can be a concern in septic shock, but it does not directly indicate severe tissue hypoxia.
D. PaCO2 58 mm Hg in (option D) is incorrect because: PaCO2 refers to the partial pressure of carbon dioxide in arterial blood and is a measure of the respiratory status. While an elevated PaCO2 can be a sign of respiratory acidosis, it is not specific to severe tissue hypoxia.
Therefore, in a critically ill patient with septic shock, an elevated lactate level, such as 9.0 mmol/L, indicates severe tissue hypoxia and inadequate oxygenation at the cellular level

A. Diarrhea B. Vomiting C. Lower GI bleed D. Tension pneumothorax E. Diabetes insipidus F. Valvular stenosis

Correct Answer is ["A","B","C","D"]

Explanation

These conditions can lead to fluid loss, either through increased gastrointestinal output (diarrhea, vomiting, lower GI bleeding) or accumulation of air in the pleural space (tension pneumothorax), resulting in a decrease in blood volume and subsequent hypovolemic shock.
E. Diabetes insipidus in (option E) is incorrect because it is not directly associated with hypovolemic shock. Diabetes insipidus is a condition characterized by excessive thirst and the production of large volumes of dilute urine due to insufficient production or response to antidiuretic hormone (ADH). While diabetes insipidus can lead to dehydration and potential hypovolemia, it is not a direct cause of hypovolemic shock.
F. Valvular stenosis in (option F) is incorrect because it is a condition characterized by the narrowing or obstruction of one or more heart valves. While it can cause problems with cardiac output and circulation, it is not specifically related to hypovolemic shock, which is caused by a decrease in blood volume.
Therefore, the conditions that can cause hypovolemic shock include diarrhea, vomiting, lower GI bleeding, and tension pneumothorax.

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A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

How does the emergency department nurse caring for a critically ill with septic shock recognize that severe tissue hypoxia is present?

Correct Answer is B

Explanation

Which conditions can cause hypovolemic shock? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

Following surgery, a patient's central venous pressure (CVP) monitor indicates high pressures. Which action will the nurse anticipate taking?

The cardiac ICU nurse is assessing a patient who is in cardiogenic shock. Which hemodynamic manifestations and/or signs and symptoms do the nurse expect? Select all that apply.

Which action should the nurse take when the low-pressure alarm sounds for a patient who has an arterial line in the right radial artery?

When caring for a patient weighing 60 kg who has just been admitted with septic shock, which of these assessment data greatest concern to the nurse?

An arterial catheter is inserted in the right radial artery to monitor a patient's blood pressure. Which information obtained by the nurse indicates that a complication of arterial pressure monitoring may be occurring?

The common denominator of all shock states is which one of the following?

The emergency department nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective by finding which one of the following?

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?