Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

Respiratory rate is 26.

+1 pedal pulses.

Body temperature is 36.8°C (rectal).

Urine output is greater than 40 cc/hr.

Answer and Explanation

The Correct Answer is D

Choice A reason:

While an increased respiratory rate can indicate a compensatory response to shock, it does not directly measure tissue perfusion. It suggests the body is attempting to improve oxygen delivery, but it is not a definitive indicator of adequate tissue perfusion.

Choice B reason:

+1 pedal pulses can indicate decreased perfusion to the extremities, but they do not provide comprehensive information about overall tissue perfusion. Peripheral pulses can be weak in shock due to vasoconstriction and poor circulation, but they are not the most reliable indicator of tissue perfusion.

Choice C reason:

Body temperature is not a direct measure of tissue perfusion. While it is important to monitor, changes in temperature can result from various factors and do not specifically reflect the adequacy of tissue perfusion.

Choice D reason:

Urine output greater than 40 cc/hr is a key indicator of adequate tissue perfusion. The kidneys are highly sensitive to changes in perfusion, and adequate urine output suggests that the kidneys are receiving sufficient blood flow to filter and excrete waste products. Monitoring urine output is a standard practice in assessing tissue perfusion and overall fluid balance in shock patients.

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Correct Answer is D

Explanation

Choice A reason:

Administering Atropine can increase the heart rate, but it is not the immediate first action. The priority is to stop the stimulus causing the vagal response, which in this case is the suctioning.

Choice B reason:

Calling the healthcare provider is important, but the immediate action should be to stop the suctioning to eliminate the cause of the vagal response. Once the immediate issue is addressed, notifying the provider can follow.

Choice C reason:

Continuing to clear the airway can exacerbate the vagal response and worsen the patient's condition. The immediate action should be to stop the suctioning.

Choice D reason:

Stopping the suctioning is the best immediate action to take when the patient becomes diaphoretic, nauseous, and experiences a significant drop in heart rate. This response is likely due to vagal stimulation, and stopping the suctioning will help alleviate the symptoms.

A. Autonomic dysreflexia B. Ischemia C. Edema D. Axial loading E. Hemorrhage

Correct Answer is ["A","B","C","E"]

Explanation

Choice A reason:

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.

Choice B reason:

Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.

Choice C reason:

Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.

Choice D reason:

Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.

Choice E reason:

Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.

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Which assessment of a patient in shock would give the nurse the most valuable information to determine there is adequate tissue perfusion?

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Naxlex Comprehensive Predictor Exams

During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

Correct Answer is D

Explanation

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Correct Answer is ["A","B","C","E"]

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