In the plan of care, the most important intervention for a patient experiencing shock is assessing:

Respirations rate.

Heart rate.

Blood pressure.

Temperature.

Answer and Explanation

The Correct Answer is C

A) Respirations rate:
Respiratory rate is an important vital sign to monitor in patients with shock, as respiratory distress can indicate inadequate oxygenation. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.

B) Heart rate:
Heart rate is an important vital sign to monitor in patients with shock, as tachycardia (rapid heart rate) may indicate the body's compensatory response to maintain cardiac output and tissue perfusion. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.

C) Blood pressure.
In shock, the body's vital organs are not receiving adequate blood flow and oxygen, leading to a life-threatening condition. While all vital signs are important to monitor in a patient experiencing shock, blood pressure is typically considered the most critical because it reflects the perfusion pressure—the force driving blood through the circulatory system to deliver oxygen and nutrients to the body's tissues. A decrease in blood pressure can indicate inadequate tissue perfusion and impending organ failure. Therefore, timely assessment and monitoring of blood pressure are essential for identifying and managing shock effectively.

D) Temperature:
Temperature monitoring is important in assessing for signs of infection or other systemic issues that may contribute to shock, such as sepsis. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.

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

Explanation

A. Diabetes: Diabetes is not typically a contraindication for decongestant use. However, patients with diabetes should be cautious with decongestants that contain sugar or other ingredients that may affect blood glucose levels.

B. Hypertension: Decongestants can cause vasoconstriction and increase blood pressure, which may exacerbate hypertension. Patients with hypertension should use decongestants cautiously and under the guidance of a healthcare provider.

C. Hyperthyroidism: While decongestants can stimulate the sympathetic nervous system and may exacerbate symptoms of hyperthyroidism such as tachycardia and palpitations, hyperthyroidism is not typically considered a contraindication for decongestant use. However, patients with hyperthyroidism should use decongestants cautiously and consult with their healthcare provider.

D. Heart disease: Decongestants can increase heart rate and blood pressure, potentially worsening symptoms in patients with heart disease such as coronary artery disease, heart failure, or arrhythmias. Patients with heart disease should use decongestants cautiously and consult with their healthcare provider before use.

E. Allergic rhinitis: Decongestants are often used to relieve nasal congestion associated with allergic rhinitis. While patients with allergic rhinitis may use decongestants, they should still use them cautiously and follow the recommended dosage instructions.

A. Montelukast B. Fluticasone C. Cromolyn D. Albuterol

Correct Answer is D

Explanation

A) Montelukast:
Montelukast is a leukotriene receptor antagonist (LTRA) used as a controller or maintenance medication for asthma. It is not used for the immediate relief of asthma symptoms during an acute attack. Montelukast is taken regularly to prevent asthma symptoms and reduce the frequency of asthma attacks, but it does not provide rapid relief during an ongoing attack.

B) Fluticasone:
Fluticasone is an inhaled corticosteroid (ICS) used as a controller medication for asthma. It works by reducing airway inflammation and is taken regularly to control asthma symptoms and prevent exacerbations. Fluticasone is not used for the immediate relief of acute asthma symptoms and is not suitable for aborting an ongoing asthma attack.

C) Cromolyn:
Cromolyn is a mast cell stabilizer used as a controller medication for asthma. It helps prevent the release of inflammatory substances that contribute to asthma symptoms. Cromolyn is taken regularly to prevent asthma symptoms and reduce the frequency of asthma attacks but is not used for the immediate relief of acute asthma symptoms like albuterol.

D) Albuterol.
Albuterol is a short-acting beta agonist (SABA) bronchodilator used for the quick relief of asthma symptoms during an acute asthma attack or exacerbation. It works rapidly to relax the smooth muscles in the airways, opening them up and relieving bronchoconstriction, which improves airflow and alleviates symptoms such as wheezing, shortness of breath, and chest tightness. Albuterol is typically administered via inhalation through a metered-dose inhaler (MDI) or a nebulizer.

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In the plan of care, the most important intervention for a patient experiencing shock is assessing:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Decongestants should be used with caution in patients with which diagnoses? (Select All that Apply.)

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

Explanation

A nurse is reinforcing teaching to a school-age child who has asthma. Which of the following medications should the nurse instruct the child to use to abort an ongoing attack?

Correct Answer is D

Explanation

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