The emergency department nurse reviews the medical record of a 41-year-old male patient with hemorrhagic shock, which contains the following information.
Physical Assessment Findings Pulse 140 beats/min and thready
Diagnostic Findings ABG respiratory acidosis
Blood pressure 60/40 mm Hg Respirations 40/min and shallow
Lactate level 7 mmol/L
All of these provider prescriptions are ordered for the patient. Which does the nurse carry out first?
Give Plasmanate 1 unit now.
Prepare for endotracheal intubation.
Give normal saline solution 250 mL/hr.
Type and crossmatch for 4 units of packed red blood cells (PRBCs).
The Correct Answer is C
Hemorrhagic shock is characterized by severe blood loss, leading to inadequate tissue perfusion and hypovolemia. The primary goal in the initial management of hemorrhagic shock is to restore intravascular volume and improve tissue perfusion. Administering intravenous fluids, such as normal saline solution, is a critical intervention to address hypovolemia and improve blood pressure.
A. Give Plasmanate 1 unit now in (option A) is incorrect because: Plasmanate is a plasma-derived product used to replace coagulation factors. While it may be necessary to address coagulation abnormalities, administering intravenous fluids to restore volume takes priority over specific blood products.
B. Prepare for endotracheal intubation in (option B) is incorrect because Endotracheal intubation may be required in cases of impending respiratory failure or compromised airway, but it should not be the first action in addressing hypovolemic shock.
D. Type and crossmatch for 4 units of packed red blood cells (PRBCs) in (option D) is incorrect because transferring packed red blood cells is an important intervention to address blood loss and improve oxygen-carrying capacity. However, before administering blood products, it is crucial to stabilize the patient's hemodynamics through fluid resuscitation.
Therefore, in a patient with hemorrhagic shock, the nurse's first priority among the given options is to give normal saline solution of 250 mL/hr to restore intravascular volume and improve tissue perfusion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["9000"]
Explanation
4 mL × body weight in kg × percentage of burn = total fluid volume for the first 24 hours Then, divide the total fluid volume by 2 to determine the fluid volume for the first 8 hours.
In this case, the patient weighs 90 kg and has a 50% burn injury.
4 mL × 90 kg × 50% = 18,000 mL (total fluid volume for 24 hours)
18,000 mL / 2 = 9,000 mL (fluid volume for the first 8 hours)
Therefore, the nurse would infuse the intravenous fluid resuscitation at a rate of 9,000 mL over the first 8 hours.
Correct Answer is B
Explanation
Central venous pressure (CVP) is a measurement of the pressure in the central veins, which reflects the blood volume and right-sided cardiac function. High CVP readings may indicate fluid overload or impaired cardiac function, and intervention is necessary to address the underlying cause.
Administering IV diuretic medications can help reduce fluid volume by increasing urine output and promoting fluid elimination. By removing excess fluid, the diuretic medications can help lower the CVP and alleviate the high pressures.
The other options mentioned are not the anticipated actions for addressing high CVP:
A. Increasing the IV fluid infusion rate in (option A) is incorrect because: If the CVP is already indicating high pressures, increasing the IV fluid infusion rate would further contribute to fluid overload and exacerbate the problem. This action would not be appropriate for high CVP readings.
C. Elevating the head of the patient's bed to 45 degrees in (option C) is incorrect because Positioning the patient with the head of the bed elevated is commonly done to prevent complications such as aspiration or improve respiratory function. While it may have other benefits, it does not directly address the high CVP.
D. Documenting the CVP and continuing to monitor in (option D) is incorrect because Documenting the CVP and continuing to monitor is important for ongoing assessment and evaluation. However, in the presence of high CVP readings, intervention is necessary to address the underlying issue rather than solely documenting and monitoring.
Therefore, when a patient's CVP monitor indicates high pressures following surgery, the nurse would anticipate administering IV diuretic medications to help reduce fluid volume and lower the CVP.
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