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

Answer and Explanation

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.

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Correct Answer is ["A","B","C","D"]

Explanation

These conditions can lead to fluid loss, either through increased gastrointestinal output (diarrhea, vomiting, lower GI bleeding) or accumulation of air in the pleural space (tension pneumothorax), resulting in a decrease in blood volume and subsequent hypovolemic shock.
E. Diabetes insipidus in (option E) is incorrect because it is not directly associated with hypovolemic shock. Diabetes insipidus is a condition characterized by excessive thirst and the production of large volumes of dilute urine due to insufficient production or response to antidiuretic hormone (ADH). While diabetes insipidus can lead to dehydration and potential hypovolemia, it is not a direct cause of hypovolemic shock.
F. Valvular stenosis in (option F) is incorrect because it is a condition characterized by the narrowing or obstruction of one or more heart valves. While it can cause problems with cardiac output and circulation, it is not specifically related to hypovolemic shock, which is caused by a decrease in blood volume.
Therefore, the conditions that can cause hypovolemic shock include diarrhea, vomiting, lower GI bleeding, and tension pneumothorax.

A. Cooling baths B. Broad-spectrum antibiotics C. Blood transfusion D. NPO status

Correct Answer is B

Explanation

The patient's symptoms of fever and elevated white blood cell count suggest a potential infection and sepsis. Broad-spectrum antibiotics should be initiated promptly to cover a wide range of possible pathogens until further diagnostic tests and identification of the specific causative agent are obtained. Early administration of appropriate antibiotics is crucial in sepsis management to target the suspected infection and improve patient outcomes.
A. Cooling baths in (option A) is incorrect because: Cooling baths are typically used in the management of hyperthermia or specific conditions like heatstroke. While the patient has an elevated temperature, it is likely due to the systemic inflammatory response rather than solely hyperthermia.
C. Blood transfusion in (option C) is incorrect because Blood transfusion may be required in certain cases of sepsis if there is evidence of significant anemia or active bleeding. However, based on the information provided, there is no immediate indication of a blood transfusion.
D. NPO status in (option D) is incorrect because NPO status (nothing by mouth) is a general precautionary measure used in various situations, such as prior to surgery or to manage gastrointestinal complications. It is not a specific intervention in the sepsis resuscitation bundle.
Therefore, the nurse should initiate the intervention of administering broad-spectrum antibiotics in this scenario.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which conditions can cause hypovolemic shock? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A 29-year-old female patient is admitted to the emergency department with two of the systemic inflammatory response syndrome variables: temperature of 101.2 °F and 14,000 per μL white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate?

Correct Answer is B

Explanation

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A 30-year-old female patient is admitted to the emergency department with two systemic inflammatory response syndrome variables: temperature of 100.2°F (35°C) and high blood sugar. Which intervention from the sepsis resuscitation bundle does the nurse initiate?

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?