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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
A. Narrowed pulse pressure: In cardiogenic shock, the cardiac output is compromised, resulting in reduced stroke volume and subsequent narrowed pulse pressure. The pulse pressure is the difference between systolic and diastolic blood pressure.
B. Tachycardia: Tachycardia is a compensatory response in cardiogenic shock, as the body attempts to increase cardiac output to maintain tissue perfusion despite decreased stroke volume. Increased heart rate is a common finding in this condition.
D. Pulmonary congestion: Cardiogenic shock is often associated with impaired left ventricular function, leading to an inadequate pump mechanism. This can result in fluid accumulation and congestion in the pulmonary circulation, leading to pulmonary edema and congestion. Patients may experience symptoms such as dyspnea, crackles on lung auscultation, and increased work of breathing.
E. Elevated pulmonary artery wedge pressure (PAWP): PAWP is a measurement obtained during invasive hemodynamic monitoring. In cardiogenic shock, the impaired left ventricular function leads to increased left atrial pressure, which is reflected by an elevated PAWP. Elevated PAWP indicates increased fluid volume and congestion in the left side of the heart.
C. Elevated SBP in (option C) is incorrect because Elevated systolic blood pressure (SBP) is not a typical finding in cardiogenic shock. Instead, hypotension or decreased blood pressure is commonly observed due to reduced cardiac output.
Correct Answer is B
Explanation
A. Oxygen saturation of 92% in (option A) is incorrect because While an oxygen saturation of 92% is suboptimal and may require intervention, it may not have the same immediate implications as low blood pressure. The healthcare provider should be informed, but addressing the blood pressure takes priority.
B. Skin cool and clammy in (option B) is correct because Cool and clammy skin is often associated with inadequate peripheral perfusion, which is a characteristic of septic shock.
C. Septic shock is characterized by systemic inflammation, vasodilation, and hypotension. Inadequate blood pressure is a significant concern in septic shock as it indicates poor tissue perfusion and compromised organ function. However, the mean arterial pressure is till acceptable.
D. Heart rate of 118 beats/minute in (option D) is incorrect because: Tachycardia is a common finding in septic shock and reflects the body's compensatory response to maintain cardiac output. While it is a significant finding, low blood pressure takes precedence in terms of urgency.
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