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 ["28"]

Explanation

To calculate the IV infusion rate in drops per minute (gtt/min), you can use the following formula:

IV infusion rate (gtt/min) =(Total volume (mL)×Drop factor (gtt/mL)) / Total time (min)

Given:

Total volume = 1000 mL

Drop factor = 10 gtt/mL

Total time = 6 hours = 6 hours × 60 minutes/hour = 360 minutes

Substitute the given values into the formula:

IV infusion rate (gtt/min) = (1000mL×10gtt/mL)/360 min

IV infusion rate (gtt/min) = 10,000/360

IV infusion rate (gtt/min)≈27.78gtt/min

Rounding to the nearest whole number, the IV infusion rate is approximately 28 gtt/min

A. The medication will relieve wheezing. B. The medication will reduce inflammation. C. The medication will increase the amount of mucus. D. The medication will decrease coughing episodes. E. The medication will open the airways.

Correct Answer is ["A","E"]

Explanation

A. The medication will relieve wheezing: Albuterol is a short-acting beta agonist bronchodilator that works by quickly relaxing the smooth muscles of the airways, leading to rapid bronchodilation. This helps relieve symptoms such as wheezing, shortness of breath, and chest tightness commonly associated with asthma exacerbations.

B. The medication will reduce inflammation: Albuterol is not primarily indicated for reducing inflammation in asthma. While it can help alleviate symptoms of bronchospasm, it does not target the underlying inflammation associated with asthma.

C. The medication will increase the amount of mucus: Albuterol does not increase mucus production. In fact, it is a bronchodilator medication that primarily targets airway smooth muscle relaxation and bronchodilation to improve airflow and relieve symptoms.

D. The medication will decrease coughing episodes: Albuterol can help decrease coughing episodes by relieving bronchospasm and improving airflow. However, its primary mechanism of action is bronchodilation rather than directly targeting coughing.

E. The medication will open the airways: Albuterol works by stimulating beta-2 adrenergic receptors in the airway smooth muscles, resulting in relaxation of these muscles and dilation of the bronchial tubes. This action helps to open the airways, allowing for improved airflow and easier breathing.

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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

Correct Answer is ["28"]

Explanation

A nurse is caring for a client who has asthma. The client asks the nurse how albuterol helps his breathing. Which of the following information should the nurse include in the response? (Select all that apply.)

Correct Answer is ["A","E"]

Explanation

A nurse is preparing to administer diphenhydramine to a client who is to receive a blood transfusion. The nurse should explain that the purpose diphenhydramine is to prevent which of the following manifestations of a transfusion reaction?

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?

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

What is the earliest sign of shock that the nurse would monitor for during a routine assessment?

A client has prescriptions for albuterol (Proventil HFA) and salmeterol (Serevent). Which instruction should the nurse provide for this client?

Patients should be advised not to overuse laxatives, because the smooth muscle in the colon can lose its tone. What condition should the nurse warn, the client can occur if this happens?

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

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?