A 27-year-old male patient who has been involved in a motor vehicle crash is admitted to the emergency department with cool, clammy skin, tachypnoea, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

Place the patient on a continuous cardiac monitor.

Administer oxygen at 100% per non-rebreather mask.

Insert two 14-gauge IV catheters.

Draw blood to type and crossmatch for transfusions.

Answer and Explanation

The Correct Answer is B

In this scenario, the patient's signs and symptoms suggest a state of shock, which can be caused by various factors, such as hypovolemia, cardiac dysfunction, or systemic vasodilation. The first priority in managing a patient in shock is to ensure adequate oxygenation and tissue perfusion. Administering oxygen at 100% per non-rebreather mask helps improve oxygen delivery to the tissues and supports vital organ function.
A. Placing the patient on a continuous cardiac monitor in (option A) is incorrect because it is an important step to monitor the patient's heart rhythm and identify any abnormalities. However, providing oxygen should take priority to address the potential hypoxemia and tissue hypoperfusion.
C. Inserting two 14-gauge IV catheters in (option C) is incorrect because it is crucial for establishing large-bore access for fluid resuscitation and medication administration. While it is an important step, addressing oxygenation takes precedence.
D. Drawing blood to type and crossmatch for transfusions in (option D) is incorrect because it is an important step in managing a patient in shock who may require blood products. However, ensuring adequate oxygenation through oxygen administration is the immediate priority.
Therefore, the nurse should act first on the order to administer oxygen at 100% per non-rebreather mask to support the patient's oxygenation and tissue perfusion.

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Correct Answer is A

Explanation

The increased respiratory rate and pulse rate can be indicators of physiological changes or potential complications in the patient's condition. These changes may suggest alterations in tissue perfusion or other underlying issues that require further assessment.
Assessing the patient's tissue perfusion includes evaluating additional vital signs, such as blood pressure, oxygen saturation, and capillary refill time. Assessing skin color, temperature, and moisture, as well as peripheral pulses, can also provide important information regarding tissue perfusion.
B. Pain medication (option B) is incorrect because the increased respiratory and pulse rates could also indicate other factors that require assessment before administering pain medication.
C. Documenting the findings in the patient's chart (option C) is incorrect because it should not be the primary action at this point. Assessing the patient's condition and determining appropriate interventions take priority.
D. Increasing the rate of the patient's IV infusion (option D) is incorrect because may not be the most appropriate action without further assessment. The patient's increased respiratory and pulse rates may not necessarily be related to hydration status, and it is important to assess the patient comprehensively before making changes to the IV infusion rate.
Therefore, the best action by the nurse in this situation is to further assess the patient's tissue perfusion to gather more information and determine the appropriate course of action.

A. Inefficient metabolism resulting from inadequate nutrition. B. Inadequate tissue perfusion results in impaired cellular metabolism. C. Vasoconstriction and reflexive vasodilation due to circulating mediators. D. Hypovolemia results from blood loss.

Correct Answer is B

Explanation

Shock is a state of inadequate tissue perfusion, resulting in compromised oxygen and nutrient delivery to cells and impaired cellular metabolism. Regardless of the specific cause or type of shock (e.g., hypovolemic, cardiogenic, distributive), the underlying problem is the failure to supply sufficient oxygen and nutrients to the body's tissues. This inadequate tissue perfusion can lead to cellular dysfunction, organ failure, and ultimately, life-threatening consequences.
A. Inefficient metabolism resulting from inadequate nutrition in (option A) is incorrect because While inadequate nutrition can contribute to the overall health status and resilience of an individual, it is not the central mechanism underlying all shock states.
C. Vasoconstriction and reflexive vasodilation due to circulating mediators in (option C) is incorrect because Vasoconstriction and vasodilation are physiological responses that can occur in various types of shock, but they are not the fundamental common denominator. Inadequate tissue perfusion remains the core issue.
D. Hypovolemia resulting from blood loss in (option D) is incorrect because Hypovolemia, which refers to decreased blood volume, is one potential cause of shock, specifically hypovolemic shock. However, other types of shock, such as cardiogenic or distributive shock, may not be primarily characterized by hypovolemia.
Therefore, the common denominator of all shock states is inadequate tissue perfusion, resulting in impaired cellular metabolism.

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A 27-year-old male patient who has been involved in a motor vehicle crash is admitted to the emergency department with cool, clammy skin, tachypnoea, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

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Naxlex Comprehensive Predictor Exams

The medical-surgical nurse is caring for a 55-year-old female patient after surgery. The patient's respiratory rate has increased from 12 to 22 breaths/min, and the pulse rate has increased from 86 to 110 beats/min since the patient was last assessed 4 hours ago. What action by the nurse is best?

Correct Answer is A

Explanation

The common denominator of all shock states is which one of the following?

Correct Answer is B

Explanation

At the beginning of your shift, you start your rounds on your patients. Upon entering this patient’s room, you observe that the cardiac monitor shows sinus tachycardia, is apneic and no pulses are palpable by the nurse. What is the first action that the nurse should take?

A 32-year-old male patient sustains 78% TBSA burn and is currently admitted to the burn unit. Which sequential order would the nurse arrange the events involved in burn shock following a patient's exposure to burns?

The surgical ICU nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock?

An emergency room nurse cares for a patient admitted with a 50% burn injury. The patient weighs 90 kg. Using the Parkland formula, calculate the rate (1st 8 hrs.) at which the nurse would infuse intravenous fluid resuscitation. (Record your answer using a whole number.)

The emergency department nurse is assessing a patient who is in the compensatory stage of hypovolemic shock. Which manifestations does the nurse expect? Select all that apply.

A 27-year-old male patient who has been involved in a motor vehicle crash is admitted to the emergency department with cool, clammy skin, tachypnoea, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?

A 40-year-old female patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on which one of the following?