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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Urine output is an essential indicator of renal perfusion and overall fluid status. In a patient in shock, maintaining an adequate urine output is a crucial goal of fluid resuscitation. A urine output of 0.5 to 1 mL/kg/hour is generally considered adequate in adults. The given value of 35 ml over the last hour suggests that the patient is producing urine, which indicates that fluid resuscitation is effective in restoring perfusion to the kidneys.
A. The patient's mean arterial pressure (MAP) is 50 mm Hg in (option A) is incorrect because While mean arterial pressure is an important hemodynamic parameter, a single value alone may not provide a comprehensive assessment of the patient's response to fluid resuscitation.
B. The patient's GCS score is 9 in (option B) is incorrect because The Glasgow Coma Scale (GCS) assesses the level of consciousness and neurological function but does not directly reflect fluid resuscitation effectiveness.
D. The patient's hemoglobin is within normal limits: (option D) is incorrect because Haemoglobin levels are important for assessing oxygen-carrying capacity but do not directly indicate the effectiveness of fluid resuscitation.
Therefore, the nurse can evaluate that fluid resuscitation for a 70 kg patient in shock is effective by observing a urine output of 35 ml over the last hour.

A. auscultate for the presence of bilateral breath sounds. B. Use an end-tidal C02 monitor to check for placement in the trachea. C. Observe the chest for symmetrical movement with ventilation. D. Obtain a portable chest radiograph to check tube placement.

Correct Answer is C

Explanation

The nurse should listen over both lung fields to ensure that air entry is present bilaterally, indicating that the tube is correctly positioned in the trachea. This comes after observing chest movements.

B. Using an end-tidal CO2 monitor to check for placement in the trachea in (option B) is incorrect because End-tidal CO2 monitoring can provide confirmation of correct tube placement in the trachea by detecting exhaled CO2 levels. However, it requires additional equipment and setup, which may not be readily available at the bedside or immediately accessible.
C. Observing the chest for symmetrical movement with ventilation is the initial action after placing an endotracheal tube.
D. Obtaining a portable chest radiograph to check tube placement (option D) is incorrect because Chest radiographs are commonly used to confirm endotracheal tube placement, especially for long-term confirmation or if there are concerns about placement. However, obtaining a portable chest radiograph may involve delays and is not the initial action to be taken for immediate verification.
Therefore, the best initial action by the nurse to verify the correct placement of an endotracheal tube (ET) after insertion is to auscultate for the presence of bilateral breath sounds.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

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

Correct Answer is C

Explanation

To verify the correct placement of an endotracheal tube (ET) after insertion, the best initial action by the nurse is to:

Correct Answer is C

Explanation

The normal pathway of the conduction system is which one of the following?

Four hours after mechanical ventilation is initiated for a patient with a suspected drug overdose, the patient's arterial blood gas (ABG) results include a pH of 7.50, Pa0 2 of 80 mm Hg. PaCO2 of 29 mmHg, and HCO3 of 23 mEq/L (23 mmo/L). The nurse will anticipate the need to:

Which of the following findings is most consistent with disseminated intravascular coagulation (DIC)?

A student is caring for a patient who suffered massive blood loss after trauma. How does the student correlate the blood loss with the patient's mean arterial pressure (MAP)?

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

The nurse needs to estimate quickly the heart rate of a patient with a regular heart rhythm. Which method will be best to use?

Which assessment information obtained by the nurse when caring for a COPD patient receiving mechanical ventilation indicates the need for suctioning?

The emergency department nurse is assessing a patient who is in the compensatory stage of hypovolemic shock. Which manifestations does the nurse expect? Select all that apply.