A client was admitted 2 days ago with early stages of shock. Today the nurse notes that the client's systolic blood pressure, pulse pressure, and cardiac output are decreasing rapidly. Which intervention does the nurse do first?
Insert a Foley catheter to monitor urine output closely
Initiate the prescribed norepinephrine intravenous drip
Initiate a rapid intravenous push (IVP) bolus of adenosine
Obtain blood cultures before administering the next dose of antibiotics
The Correct Answer is B
Choice A reason: Inserting a Foley catheter is an essential nursing intervention to monitor renal perfusion via hourly urine output during shock. However, this is a monitoring tool rather than a corrective action. In the progressive stage of shock, restoring systemic perfusion and blood pressure takes precedence over the initiation of output monitoring.
Choice B reason: Initiating norepinephrine is the priority because the client is demonstrating signs of the progressive stage of shock, characterized by a rapid decline in cardiac output and blood pressure. Norepinephrine is a potent vasoconstrictor and alpha-1 agonist that increases systemic vascular resistance and mean arterial pressure to maintain vital organ perfusion.
Choice C reason: Administering an intravenous push of adenosine is contraindicated in this clinical scenario. Adenosine is an antiarrhythmic medication used specifically for the conversion of supraventricular tachycardia to sinus rhythm. Giving it to a client with decreasing cardiac output and hypotension would further compromise their hemodynamic stability and could lead to cardiac arrest.
Choice D reason: Obtaining blood cultures is a critical step in the management of septic shock to guide antimicrobial therapy. However, when a client's hemodynamic status is rapidly deteriorating (evidenced by falling systolic pressure and cardiac output), the immediate priority is physiological stabilization through vasopressors or fluids rather than diagnostic laboratory collection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This response is dismissive, impatient, and judgmental. It fails to validate the patient’s experience and ignores the fact that phantom limb pain is a documented neurological phenomenon that requires appropriate clinical management rather than just "acceptance" by the patient.
Choice B reason: Phantom limb pain is a very real sensation experienced by many amputees due to the reorganization of the somatosensory cortex. The nurse's first action should always be a thorough assessment. Asking the patient to describe the pain helps determine its quality, intensity, and appropriate pharmacological interventions.
Choice C reason: While non-pharmacological interventions like imagery or mirror therapy can be helpful in managing phantom limb pain, the nurse must first perform a complete assessment of the pain. Offering a solution before fully understanding the nature of the pain is premature and skips a vital step.
Choice D reason: This statement is medically incorrect and highly unprofessional. Telling a patient their pain "does not exist" is gaslighting. Phantom limb pain is a complex physiological and psychological condition caused by genuine nerve signaling in the brain and spinal cord, regardless of the limb's absence.
Correct Answer is B
Explanation
Choice A reason: This client is exhibiting signs of emotional distress and potential depression related to their injury. While psychological support is a critical component of burn rehabilitation, it is not a life-threatening emergency and does not take priority over hemodynamic instability or acute physiological decline.
Choice B reason: This client is demonstrating signs of hypovolemic shock or early sepsis, evidenced by hypotension (MAP < 65 mm Hg). In burn patients, fluid shifts and loss of skin barrier make them highly susceptible to circulatory collapse. Immediate assessment and fluid resuscitation are required to prevent organ failure.
Choice C reason: Postoperative pain is expected and requires intervention; however, pain is not more stable than a compromised blood pressure. While the nurse should address the pain promptly, the client with hemodynamic instability represents a higher risk for immediate mortality and must be assessed first.
Choice D reason: A potassium level of 5.0 mEq/L is at the high end of normal, and a hematocrit of 55% is common in the first 24 hours of burn care due to hemoconcentration. These findings are expected in the emergent phase and do not require more immediate action than hypotension.
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