A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. ordered by the health care provider should the nurse implement first?

Insert two large-bore IV catheters.

Provide oxygen at 100% per non-rebreather mask.

Draw blood to type and crossmatch for transfusions. Initiate continuous

electrocardiogram (ECG) monitoring.

Answer and Explanation

The Correct Answer is B

Cool, clammy skin, tachycardia, and hypotension are signs of shock, indicating inadequate tissue perfusion and oxygenation. The immediate priority is to ensure adequate oxygen delivery to the tissues. Providing oxygen at 100% via a non-rebreather mask helps increase the patient's oxygen saturation and improve tissue oxygenation.
While all the options mentioned are important in the management of a patient in shock, oxygenation takes priority as it directly addresses compromised tissue perfusion and oxygenation.
A. Inserting two large-bore IV catheters in (option A) is incorrect because: Establishing intravenous access is crucial for fluid resuscitation and administration of medications, but it can be done after ensuring adequate oxygenation.
C. Drawing blood to type and crossmatch for transfusions in (option C) is incorrect because Blood typing and crossmatching are important for potential blood transfusions but should not be the first action in this critical situation.
D. Initiating continuous electrocardiogram (ECG) monitoring in (option D) is incorrect because Continuous ECG monitoring is important for assessing cardiac rhythm and detecting any dysrhythmias, but ensuring oxygenation should be the initial priority.
Therefore, in a patient presenting with cool, clammy skin, tachycardia, and hypotension, the nurse should first provide oxygen at 100% via a non-rebreather mask to address inadequate tissue perfusion and oxygenation.

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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.

A. Decreased blood volume B. Increased Increased vascular permeability C. peripheral resistance D. Development of edema

Correct Answer is A,B,D,C

Explanation

A. Decreased blood volume: Burn injuries can lead to fluid loss, primarily through damaged skin. This fluid loss causes a decrease in blood volume, leading to hypovolemia. Hypovolemia contributes to decreased cardiac output and tissue perfusion.
B. Increased vascular permeability: Burn injuries cause an inflammatory response, leading to increased vascular permeability. This increased permeability allows fluid, electrolytes, and proteins to leak from the intravascular space into the interstitial space.
C. Development of edema: The increased vascular permeability and fluid leakage lead to the development of edema. Edema occurs as fluid accumulates in the interstitial spaces, further contributing to tissue swelling and compromised perfusion.
D. Increased peripheral resistance: In response to decreased blood volume and tissue hypoperfusion, the body activates compensatory mechanisms to maintain blood pressure and tissue perfusion. One of these mechanisms is increased peripheral resistance, which occurs as blood vessels constrict to maintain blood pressure. Increased peripheral resistance helps redirect blood flow to vital organs but also contributes to increased workload on the heart.
Therefore, the correct sequential order of events involved in burn shock following a patient's exposure to burns is:
A. Decreased blood volume B. Increased vascular permeability D. Development of edema C. Increased peripheral resistance

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A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. ordered by the health care provider should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patients in shock receive fresh frozen plasma to replace which one of the following?

Correct Answer is B

Explanation

A 32-year-old male patient sustains 78% TBSA burn and is currently admitted to the burn unit. Which sequential order would the nurse arrange the events involved in burn shock following a patient's exposure to burns?

Correct Answer is A,B,D,C

Explanation

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