The emergency department nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective by finding which one of the following?
The patient's mean arterial pressure (MAP) is 50 mm Hg.
The patient's GCS score is 9.
The patient's urine output has been 35 ml over the last hour.
The patient's hemoglobin is within normal limits.
The Correct Answer is C
Urine output is an essential indicator of renal perfusion and overall fluid status. In a patient in shock, maintaining an adequate urine output is a crucial goal of fluid resuscitation. A urine output of 0.5 to 1 mL/kg/hour is generally considered adequate in adults. The given value of 35 ml over the last hour suggests that the patient is producing urine, which indicates that fluid resuscitation is effective in restoring perfusion to the kidneys.
A. The patient's mean arterial pressure (MAP) is 50 mm Hg in (option A) is incorrect because While mean arterial pressure is an important hemodynamic parameter, a single value alone may not provide a comprehensive assessment of the patient's response to fluid resuscitation.
B. The patient's GCS score is 9 in (option B) is incorrect because The Glasgow Coma Scale (GCS) assesses the level of consciousness and neurological function but does not directly reflect fluid resuscitation effectiveness.
D. The patient's hemoglobin is within normal limits: (option D) is incorrect because Haemoglobin levels are important for assessing oxygen-carrying capacity but do not directly indicate the effectiveness of fluid resuscitation.
Therefore, the nurse can evaluate that fluid resuscitation for a 70 kg patient in shock is effective by observing a urine output of 35 ml over the last hour.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Assessing tissue perfusion is crucial in evaluating the adequacy of oxygen and nutrient delivery to the body's tissues. While multiple factors contribute to tissue perfusion, the options provided in choice B are key indicators:
Level of consciousness: Altered mental status or changes in the patient's level of consciousness can be a sign of impaired cerebral perfusion, which reflects overall tissue perfusion.
Urine output: Monitoring urine output provides information about renal perfusion and kidney function. Decreased urine output can be indicative of inadequate tissue perfusion.
Lactate level: Lactate is a by-product of anaerobic metabolism that accumulates when there is insufficient oxygen delivery to tissues. Elevated lactate levels indicate tissue hypoperfusion and cellular oxygen debt.
A. Pupil response, pulse pressure, and urine output in (option A) are incorrect because While pupil response and pulse pressure may provide some information about perfusion, they do not encompass a comprehensive assessment of tissue perfusion. Additionally, assessing urine output is important, but it alone may not provide a complete picture of tissue perfusion status.
C. Blood pressure, pulse, and respirations in (option C) are incorrect because Blood pressure, pulse, and respirations are important vital signs to monitor, but they do not solely indicate tissue perfusion. Hypotension, for example, can be a late sign of inadequate tissue perfusion.
D. Breath sounds, heart rate, and pupil response in (option D) are incorrect because: Although breath sounds and heart rate can be affected by changes in tissue perfusion, they are not specific or comprehensive indicators of tissue perfusion status. Pupil response alone does not provide a complete assessment of tissue perfusion.
Therefore, the most accurate assessment of tissue perfusion in a patient in shock involves evaluating the level of consciousness, urine output, and lactate levels.
Correct Answer is D
Explanation
Septic shock is a life-threatening condition characterized by severe infection, systemic inflammation, and inadequate tissue perfusion. Hypotension, as indicated by a low blood pressure reading, is a significant concern in septic shock. It reflects inadequate perfusion to vital organs and tissues, leading to potential organ dysfunction and damage.
While all the assessment data provided may be important and require attention, the low blood pressure (BP) reading indicates impaired systemic perfusion and can contribute to end-organ damage. The nurse should prioritize interventions aimed at improving perfusion and stabilizing the patient's blood pressure.
A. Arterial oxygen saturation is 90% in (option A) is incorrect because While an arterial oxygen saturation of 90% is below the desired range, it is not as immediately life-threatening as low blood pressure. Oxygen therapy and interventions to improve oxygenation should still be initiated, but addressing hypotension takes priority.
B. Urine output of 15 ml for 2 hours in (option B) is incorrect because Decreased urine output is a concerning sign, as it may indicate impaired renal perfusion. However, the immediate concern in septic shock is addressing the low blood pressure to improve overall perfusion, including renal perfusion.
C. Apical pulse 110 beats/min in (option C) is incorrect because: Tachycardia is a common finding in septic shock and represents the body's compensatory response to maintain cardiac output. While it requires monitoring and consideration, low blood pressure is a more significant concern.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today