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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Free Nursing Study Resources

Correct Answer is C

Explanation

A) Increase dosing with a large meal:
Increasing the dosing with a large meal may not be appropriate as it could lead to overdosing and potential side effects. The dosage of pancrelipase should be determined by the healthcare provider based on the individual's needs and response to treatment. There's no evidence to support the need for increased dosing with larger meals.

B) Take the medication at least 2 hours prior to meals:
Taking the medication prior to meals may not be effective as the enzymes will not be available when food is consumed, which defeats the purpose of enzyme replacement therapy. The enzymes need to be present simultaneously with the food to aid in digestion. Waiting 2 hours before meals would mean the enzymes are not available when needed.

C) Take the medication with meals.
Pancrelipase, such as Cotazym, is a pancreatic enzyme replacement therapy used to aid in the digestion of fats, proteins, and carbohydrates in individuals with pancreatic insufficiency. Taking the medication with meals is crucial because it helps ensure that the enzymes are available to aid in the digestion of food. Without proper enzyme supplementation during meals, individuals with pancreatic insufficiency may experience malabsorption, leading to nutritional deficiencies and gastrointestinal symptoms.

D) Decrease fluid intake:
Decreasing fluid intake is not appropriate as it could lead to dehydration and may not have any significant impact on the efficacy of pancrelipase. In fact, adequate fluid intake is important for digestion and overall health. There's no indication that fluid intake needs to be decreased when taking pancrelipase.

A. 250 mL/hr and 45 drops/min B. 200 mL/hr and 45 drops/min C. 200 mL/hr and 50 drops/min D. 250 mL/hr and 50 drops/min

Correct Answer is C

Explanation

To calculate the rate of administration in milliliters per hour (mL/hr):

First, find the total volume to be infused: 1000 mL

Next, divide the total volume by the total time in hours: 1000 mL ÷ 5 hours = 200 mL/hr

Therefore, you will administer the solution at a rate of 200 mL/hr.

To calculate the rate of administration in drops per minute (drops/min):

First, find the total drops: 1000 mL × 15 drops/mL = 15,000 drops

Next, divide the total drops by the total time in minutes: 15,000 drops ÷ (5 hours × 60 minutes/hour) = 50 drops/min

Therefore, you will administer the solution at a rate of 200 mL/hr and 50 drops/min.

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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

Which instruction is most appropriate for a client who is prescribed pancrelipase (Cotazym)?

Correct Answer is C

Explanation

The healthcare provider has ordered 1000 mL of 0.9% sodium chloride to be administered intravenously over 5 hours. The drop factor on the tubing is 15 drops/mL. How many milliliters per hour will you administer and how many drops per minute?

Correct Answer is C

Explanation

The nurse explains to the client the different ways to administer inhalation medications. Which administration technique should be included in the teach session? (Select All that Apply.)

A client has been diagnosed with allergic rhinitis. Which symptoms would the nurse expect to observe? (Select All that Apply.)

A nurse is assisting in the care of a client who is receiving a dopamine infusion at a low dose for treatment of shock. Which of the following findings is an expected effect of this medication?

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An ulcer caused by H. pylori can be successfully treated with which classification of drugs?

The nurse is teaching a client about digestion. Which statement reflects that the client understands the teaching?