A patient with new third-degree burns over 60% of the body is confused and presents with a blood pressure of 79/56 mm Hg, heart rate of 132 beats/min, and respirations of 28 breaths/min with crackles on auscultation.
The patient’s body temperature is 76° F, and the skin is pale and clammy. Which stage of shock is this patient experiencing?
Irreversible.
End-organ dysfunction.
Early reversible.
Preshock.
The Correct Answer is C
Choice A rationale:
Irreversible shock is the final stage of shock, where the body's compensatory mechanisms have failed, and damage to vital organs is irreversible. This stage is characterized by:
Profound hypotension (systolic blood pressure persistently below 60 mmHg) Severely altered mental status (unresponsiveness or coma)
Widespread organ failure (kidney failure, liver failure, respiratory failure) Lack of response to aggressive fluid resuscitation and vasopressor therapy
The patient in the question does not exhibit all of these signs and symptoms, particularly the profound hypotension and irreversible organ failure. Therefore, irreversible shock is not the most likely stage.
Choice B rationale:
End-organ dysfunction is a stage of shock where inadequate tissue perfusion has begun to cause damage to vital organs. This stage is characterized by:
Hypotension that may respond to fluid resuscitation
Signs of organ dysfunction, such as decreased urine output, altered mental status, or respiratory distress
The patient in the question does have some signs of organ dysfunction, such as confusion and crackles on lung auscultation. However, the hypotension is not as severe as typically seen in end-organ dysfunction shock, and there is no mention of other organ dysfunction like decreased urine output. Therefore, end-organ dysfunction is not the most likely stage.
Choice C rationale:
Early reversible shock is the initial stage of shock, where the body's compensatory mechanisms are still able to maintain blood pressure and organ perfusion. This stage is characterized by:
Mild to moderate hypotension Tachycardia
Cool, clammy skin Narrowed pulse pressure Restlessness or anxiety
The patient in the question presents with all of these signs and symptoms, making early reversible shock the most likely stage.
Choice D rationale:
Preshock is a state of impending shock, where the body's compensatory mechanisms are activated but not yet fully effective. This stage is characterized by:
Normal or slightly low blood pressure Tachycardia
Cool, clammy skin Restlessness or anxiety
The patient in the question has hypotension, which is not consistent with preshock. Therefore, preshock is not the correct stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Removing the tube immediately upon patient gagging is not the most appropriate first step. Gagging is a common reflex during nasogastric tube insertion and can often be managed without removing the tube.
Premature removal could lead to unnecessary discomfort for the patient and potential delays in treatment.
The nurse should attempt to reposition the tube or have the patient sip water to facilitate passage before considering removal.
Choice B rationale:
Tucking the chin to the chest and swallowing are essential maneuvers that help guide the tube into the esophagus and reduce the risk of misplacement into the trachea.
These actions close off the airway and open the esophagus, creating a smoother path for the tube.
The nurse should instruct the patient to perform these actions during insertion to promote successful placement.
Choice C rationale:
While a supine position is often used for nasogastric tube insertion, it is not the most crucial factor for success.
Studies have shown that a high-Fowler's position (sitting upright with head elevated) may be equally effective and potentially more comfortable for patients.
The nurse should consider patient comfort and potential contraindications (such as respiratory distress) when choosing the most appropriate position.
Choice D rationale:
Measuring the tube from the nose tip to the navel is an outdated practice that can lead to inaccurate placement. The correct measurement is from the nose tip to the earlobe to the xiphoid process (NEX).
This landmark-based method provides a more reliable estimation of the distance to the stomach.
Correct Answer is C
Explanation
Choice A rationale:
Bilateral flank pain is not a typical sign of an allergic blood transfusion reaction. It can be associated with other conditions, such as kidney problems, musculoskeletal issues, or abdominal aortic aneurysm. While it's important to assess flank pain, it doesn't directly suggest an allergic reaction to the transfusion.
Choice B Rationale:
Distended jugular veins can indicate fluid overload, which could potentially occur during a transfusion. However, it's not a specific sign of an allergic reaction. Fluid overload can result from various causes, including heart failure, kidney problems, or excessive fluid intake. It's crucial to monitor for fluid overload during transfusions, but it doesn't definitively point to an allergic reaction.
Choice C Rationale:
Generalized urticaria, or hives, is a hallmark sign of an allergic reaction. It's characterized by raised, red, itchy welts that can appear on various parts of the body. Hives can develop rapidly and spread extensively. During a blood transfusion, generalized urticaria strongly suggests that the patient's immune system is reacting to a component of the transfused blood, such as proteins or antibodies.
Choice D Rationale:
Blood pressure 184/92 mm Hg is elevated and could be concerning, but it's not specific to allergic reactions. High blood pressure can have various causes, including stress, pain, anxiety, or underlying hypertension. While monitoring blood pressure during transfusions is essential, it doesn't directly indicate an allergic reaction.
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