What typical sign/symptom indicates the early stage of septic shock?
Tachypnoea and tachycardia
Pallor and cool skin
Blood pressure 84/50 mm Hg
Respiratory acidosis
The Correct Answer is A
In the early stage of septic shock, the body initiates compensatory mechanisms to combat the infection and restore adequate tissue perfusion. Tachypnoea (rapid breathing) and tachycardia (elevated heart rate) are common early signs of septic shock.
Tachypnoea occurs as a response to increased metabolic demand and to compensate for impaired oxygenation and tissue perfusion. Tachycardia is the body's attempt to maintain cardiac output and compensate for decreased blood pressure.
B. Pallor and cool skin in (option B) is incorrect because Pallor and cool skin can occur in later stages of septic shock when perfusion to the peripheral tissues is compromised. However, they are not specific to the early stage.
C. Blood pressure 84/50 mm Hg in (option C) is incorrect because A blood pressure reading of 84/50 mm Hg indicates hypotension, which is typically seen in later stages of septic shock. In the early stage, blood pressure may still be within normal or slightly decreased range.
D. Respiratory acidosis in (optionD) is incorrect because: Respiratory acidosis refers to an imbalance in acid-base status and is not specific to the early stage of septic shock. Acid-base disturbances may occur at any stage of shock but are not indicative of the early stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
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.
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