The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?
Oxygen saturation 92%
Skin cool and clammy
Blood pressure (BP) 92/56 mm Hg
Heart rate 118 beats/minute
The Correct Answer is B
A. Oxygen saturation of 92% in (option A) is incorrect because While an oxygen saturation of 92% is suboptimal and may require intervention, it may not have the same immediate implications as low blood pressure. The healthcare provider should be informed, but addressing the blood pressure takes priority.
B. Skin cool and clammy in (option B) is correct because Cool and clammy skin is often associated with inadequate peripheral perfusion, which is a characteristic of septic shock.
C. Septic shock is characterized by systemic inflammation, vasodilation, and hypotension. Inadequate blood pressure is a significant concern in septic shock as it indicates poor tissue perfusion and compromised organ function. However, the mean arterial pressure is till acceptable.
D. Heart rate of 118 beats/minute in (option D) is incorrect because: Tachycardia is a common finding in septic shock and reflects the body's compensatory response to maintain cardiac output. While it is a significant finding, low blood pressure takes precedence in terms of urgency.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Assessing the patient's level of consciousness is a critical initial step in evaluating a patient with shock. Altered mental status or decreased level of consciousness can be indicative of inadequate cerebral perfusion and may require immediate interventions to address compromised brain function and ensure patient safety.
While all the options mentioned are important in the assessment and management of a patient in shock, checking the level of consciousness takes priority as it provides essential information about the patient's neurological status and helps guide further interventions.
A. Obtaining the blood pressure in (option A) is incorrect because Assessing blood pressure is crucial in evaluating a patient in shock, but it can be done in conjunction with checking the level of consciousness and other vital signs.
C. Administering oxygen in (option C) is incorrect because: Administering oxygen is important in managing shock, as tissue hypoxia is a key concern. However, it can be done simultaneously with assessing the level of consciousness and initiating other interventions.
D. Obtaining a 12-lead electrocardiogram (ECG) in (option D) is incorrect because While an ECG may provide valuable information about the patient's cardiac function, it is not the first priority in a patient with shock of unknown etiology. Assessing the level of consciousness and vital signs takes precedence.
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.
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