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 B
Explanation
A. Auscultate for the presence of bilateral breath sounds.
It's an important check, but it is not the most reliable initial method because breath sounds can sometimes be misleading (for example, sounds may be heard in the stomach or transmitted incorrectly).
B. Use an end-tidal CO₂ monitor to check for placement in the trachea.
It's the correct answer. Continuous waveform capnography or end-tidal CO₂ detection is the most reliable and immediate method to confirm that the endotracheal tube is in the trachea and not in the esophagus. Presence of CO₂ indicates effective airway placement.
C. Observe the chest for symmetrical movement with ventilation.
Chest rise is helpful, but it is not specificboth esophageal and tracheal intubation may show chest movement.
D. Obtain a portable chest radiograph to check tube placement.
It's the gold standard for final confirmation, but it is not the initial bedside method because it takes time.
Correct Answer is D
Explanation
In the compensatory stage of shock, the body initiates various mechanisms to maintain perfusion to vital organs and restore homeostasis. Activation of the renin-angiotensin system is one of the compensatory responses. The decreased blood flow and oxygen delivery to the kidneys stimulate the release of renin from the kidneys. Renin acts on angiotensinogen, converting it into angiotensin I, which is further converted to angiotensin II by the action of angiotensin-converting enzyme (ACE). Angiotensin II is a potent vasoconstrictor and also stimulates the release of aldosterone, leading to sodium and water retention. These mechanisms aim to increase blood pressure and cardiac output and restore fluid balance.
A. The initial stage of shock in (option A) is incorrect because it is characterized by inadequate tissue perfusion and the activation of various compensatory mechanisms, including the release of stress hormones. However, the renin-angiotensin system is not specifically mentioned as activated in this stage.
B. The progressive stage of shock in (option B) is incorrect because it occurs when compensatory mechanisms fail to maintain adequate perfusion, leading to worsening hypoperfusion and organ dysfunction. The renin-angiotensin system continues to be activated during this stage, but it is primarily associated with the compensatory stage.
C. The refractory stage of shock in (option C) is incorrect because it is the stage of severe and prolonged hypoperfusion, where organ failure becomes irreversible. The renin-angiotensin system may still be activated, but it is not the primary focus of this stage.
Therefore, the activation of the renin-angiotensin system occurs during the compensatory stage of shock.
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