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 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.
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.
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 to 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.
Correct Answer is C
Explanation
A) Nighttime pain:
Nighttime pain, also known as nocturnal pain, is a symptom associated with both duodenal and gastric ulcers. It occurs when the stomach or duodenal lining is empty and no food is present to buffer the effect of gastric acid. While nighttime pain can occur in both types of ulcers, it is not more specific to duodenal ulcers compared to gastric ulcers.
B) Anorexia:
Anorexia, or loss of appetite, can occur in both duodenal and gastric ulcers due to factors such as pain, discomfort, and inflammation. It is not a symptom that is more commonly associated with one type of ulcer over the other.
C) Postprandial pain (occurring after a meal).
Postprandial pain, which occurs after a meal, is more commonly associated with duodenal ulcers than gastric ulcers. This pain typically occurs 2 to 3 hours after eating, as it is often triggered by the release of gastric acid and duodenal contractions stimulated by food intake. Duodenal ulcers tend to cause this type of pain because they are located in the duodenum, the first part of the small intestine, which is exposed to gastric acid and bile after a meal.
D) Nausea and vomiting:
Nausea and vomiting can occur in both duodenal and gastric ulcers, particularly if the ulcer is accompanied by complications such as obstruction or perforation. These symptoms are not more specific to duodenal ulcers compared to gastric ulcers.
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