At the beginning of your shift, you start your rounds on your patients. Upon entering this patient’s room, you observe that the cardiac monitor shows sinus tachycardia, is apneic and no pulses are palpable by the nurse.
What is the first action that the nurse should take?
Administer the prescribed Beta-Blocker
Prepare for Cardioversion per hospital protocol.
Give 100% oxygen per non-rebreather mask.
Start CPR
The Correct Answer is D
The absence of palpable pulses suggests a lack of effective cardiac output, and the patient is in cardiac arrest. In this situation, immediate initiation of cardiopulmonary resuscitation (CPR) is crucial to maintain circulation and provide oxygenation to vital organs.
CPR consists of chest compressions and rescue breaths to circulate oxygenated blood to the brain and other vital organs. It is the primary intervention in cardiac arrest to provide temporary life support until advanced cardiac life support (ACLS) measures, such as defibrillation or medication administration, can be initiated.
A. Administering the prescribed Beta-Blocker in (option A) is incorrect because Administering a beta-blocker is not the initial action in a patient who is in cardiac arrest and requires immediate resuscitation.
B. Prepare for Cardioversion per hospital protocol (option B) is incorrect because Cardioversion, which is the delivery of an electric shock to the heart, may be considered in certain situations like unstable ventricular tachycardia or certain supraventricular tachycardias. However, in the given scenario, the patient is unresponsive and has no pulses, indicating cardiac arrest where CPR takes precedence over cardioversion.
C. Give 100% oxygen per non-rebreather mask in (option C) is incorrect because: While oxygenation is important, it should not delay or replace the initiation of CPR, which is the immediate priority in a patient without palpable pulses.
Therefore, the first action that the nurse should take in this scenario is to start CPR.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Septic shock is a life-threatening condition characterized by severe infection, systemic inflammation, and inadequate tissue perfusion. Hypotension, as indicated by a low blood pressure reading, is a significant concern in septic shock. It reflects inadequate perfusion to vital organs and tissues, leading to potential organ dysfunction and damage.
While all the assessment data provided may be important and require attention, the low blood pressure (BP) reading indicates impaired systemic perfusion and can contribute to end-organ damage. The nurse should prioritize interventions aimed at improving perfusion and stabilizing the patient's blood pressure.
A. Arterial oxygen saturation is 90% in (option A) is incorrect because While an arterial oxygen saturation of 90% is below the desired range, it is not as immediately life-threatening as low blood pressure. Oxygen therapy and interventions to improve oxygenation should still be initiated, but addressing hypotension takes priority.
B. Urine output of 15 ml for 2 hours in (option B) is incorrect because Decreased urine output is a concerning sign, as it may indicate impaired renal perfusion. However, the immediate concern in septic shock is addressing the low blood pressure to improve overall perfusion, including renal perfusion.
C. Apical pulse 110 beats/min in (option C) is incorrect because: Tachycardia is a common finding in septic shock and represents the body's compensatory response to maintain cardiac output. While it requires monitoring and consideration, low blood pressure is a more significant concern.
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