In the plan of care, the most important intervention for a patient experiencing shock is assessing:
Respirations rate.
Heart rate.
Blood pressure.
Temperature.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","E"]
Explanation
A. The inside surface of the lungs is small, and the dose is concentrated in that area: Inhalation medications are delivered directly to the lungs, where they are rapidly absorbed due to the small surface area and the close proximity of the medication to the lung tissue.
B. There is a large surface area inside the lungs: The lungs have a large surface area for gas exchange, allowing for efficient absorption of inhaled medications into the bloodstream.
C. Inhaled medications are given at very high doses: Inhaled medications are typically given at therapeutic doses appropriate for the patient's condition. While they may be given in higher doses compared to oral medications in some cases, the dosage is carefully adjusted based on factors such as the patient's age, weight, and severity of the condition.
D. Inhaled medications are given with food: Inhaled medications are typically administered separately from meals. Food can interfere with the absorption of inhaled medications and may affect their effectiveness.
E. There is a rich blood supply to the lungs: The lungs have a rich network of blood vessels, known as pulmonary capillaries, which allows for rapid absorption of inhaled medications into the bloodstream.
Correct Answer is A
Explanation
A) The nose, nasal cavity, pharynx, and paranasal sinuses.
The upper respiratory tract consists of the structures located above the larynx (voice box). These include the nose, nasal cavity, pharynx (throat), and paranasal sinuses. These structures play vital roles in filtering, warming, and humidifying the air we breathe, as well as in olfaction (sense of smell) and speech resonance.
B) The nose and paranasal sinuses:
While the nose and paranasal sinuses are indeed part of the upper respiratory tract, this response does not include the entirety of the upper respiratory structures, such as the pharynx, which is also crucial.
C) The lungs and associated structures:
This choice is incorrect because the lungs are part of the lower respiratory tract, not the upper respiratory tract. The lower respiratory tract includes the trachea (windpipe), bronchi, bronchioles, and alveoli.
D) The nose, nasal cavity, pharynx, and the lungs:
This response includes structures from both the upper and lower respiratory tracts. While the nose, nasal cavity, and pharynx belong to the upper respiratory tract, the lungs are part of the lower respiratory tract. Therefore, this option is not accurate for describing the components of the upper respiratory tract.
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