When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the emergency department nurse will anticipate the administration of large volumes of Lactated Ringers (LR) when which one of the following occurs?
The mean arterial pressure (MAP) is 50 mm Hg.
Cardiac Out (CO) is 4 L/min
Stroke volume 70 ml/beat
The heart rate is 80 bpm.
The Correct Answer is A
Mean arterial pressure (MAP) is a measure of the average pressure within the arteries during one cardiac cycle. It represents the perfusion pressure that drives blood flow to organs and tissues. In the context of shock, a MAP of 50 mm Hg is considered low and indicates inadequate tissue perfusion.
To improve tissue perfusion and restore blood pressure, the nurse would anticipate administering large volumes of intravenous fluids, such as Lactated Ringers (LR). Fluid resuscitation aims to increase intravascular volume and improve cardiac output, ultimately leading to improved tissue perfusion.
B. Cardiac Output (CO) is 4 L/min in (option A) is incorrect because Cardiac output represents the volume of blood pumped by the heart per minute. While a low cardiac output may require intervention, it does not specifically indicate the need for large volumes of fluid administration.
C. Stroke volume is 70 ml/beat in (option C) is incorrect because Stroke volume refers to the volume of blood ejected by the heart with each contraction. While stroke volume can be an important determinant of cardiac output, it alone does not indicate the need for large fluid volumes.
D. The heart rate is 80 bpm in (option D) is incorrect because: Heart rate is the number of heartbeats per minute. While the heart rate can impact cardiac output, it does not provide direct information about fluid resuscitation needs.
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 A
Explanation
The characteristics described in the monitor strip analysis suggest ventricular tachycardia. The absence of a visible P wave and the wide and distorted QRS complex indicates that the electrical impulse is originating in the ventricles rather than the atria. The ventricular rate of 196 and regular R-R intervals further support the diagnosis of ventricular tachycardia.
B. Atrial fibrillation in (option B) is incorrect because it is characterized by irregularly irregular R-R intervals and the absence of discernible P waves. The QRS complex is typically narrow
C. Atrial tachycardia in (option C) is incorrect because it would have a rapid atrial rate with regular R-R intervals, and P waves may or may not be discernible. The QRS complex is typically narrow.
D. Ventricular fibrillation in (option D) is incorrect because it would present as a chaotic, rapid, and irregular electrical activity with no discernible P waves, QRS complexes, or regular R-R intervals. It is a life-threatening emergency that requires immediate defibrillation.
Therefore, based on the provided information, the nurse would interpret the patient's cardiac rhythm as ventricular tachycardia. However, it is important to note that an accurate interpretation should be made by a qualified healthcare professional, and the patient's clinical context should also be considered.
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