A nurse is caring for a client in the ICU with suspected cardiogenic shock following a myocardial infarction. The client has a blood pressure of 85/50 mm Hg and cool, clammy skin. Which intervention should the nurse prioritize?

Administer IV diuretics

Initiate intra-aortic balloon pump therapy

Administer IV fluids

Start supplemental oxygen

Answer and Explanation

The Correct Answer is B

Choice A reason: IV diuretics reduce fluid overload in conditions like heart failure, but in cardiogenic shock, low blood pressure (85/50 mm Hg) and cool, clammy skin indicate poor cardiac output. Diuretics worsen hypoperfusion by reducing preload, making them contraindicated. Mechanical support like an intra-aortic balloon pump is needed to improve cardiac output and perfusion.

Choice B reason: Cardiogenic shock post-myocardial infarction, with blood pressure 85/50 mm Hg and cool, clammy skin, indicates inadequate cardiac output. Intra-aortic balloon pump therapy augments coronary perfusion and reduces afterload, improving cardiac function and tissue perfusion. The ABCDE approach prioritizes circulation, making this the critical intervention to stabilize the client’s hemodynamics.

Choice C reason: IV fluids may be used in hypovolemic shock but can worsen cardiogenic shock by increasing preload on a failing heart. Low blood pressure and clammy skin reflect poor cardiac output, not volume loss. Fluid administration risks pulmonary edema, making it inappropriate compared to mechanical support like an intra-aortic balloon pump.

Choice D reason: Supplemental oxygen improves oxygenation in hypoxemia, but cardiogenic shock’s primary issue is poor cardiac output, as evidenced by low blood pressure and clammy skin. Oxygen does not address pump failure. The ABCDE approach prioritizes circulation, making intra-aortic balloon pump therapy the priority to restore perfusion in this critical condition.

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Correct Answer is D

Explanation

Choice A reason: IV proton pump inhibitors reduce gastric acid, preventing ulcer-related bleeding, but variceal bleeding in cirrhosis results from portal hypertension, not acid-related injury. Hematemesis risks airway aspiration, making airway assessment the priority. Proton pump inhibitors are supportive but not the first action in acute variceal bleeding with potential airway compromise.

Choice B reason: Endoscopic band ligation is a definitive treatment for variceal bleeding, occluding bleeding esophageal varices. However, it requires preparation and sedation, delaying intervention. Hematemesis and tachycardia suggest active bleeding, risking airway aspiration. The ABCDE approach prioritizes airway assessment to ensure patency before procedural interventions like endoscopy.

Choice C reason: IV vasopressin reduces portal pressure, controlling variceal bleeding, but it acts over time and may cause vasoconstriction-related complications. Hematemesis poses an immediate airway risk due to aspiration. The ABCDE approach prioritizes airway and breathing assessment to prevent respiratory compromise, making vasopressin a secondary intervention in this acute scenario.

Choice D reason: Hematemesis in variceal bleeding risks airway aspiration, a life-threatening complication, especially with tachycardia indicating hypovolemia. Assessing airway and breathing ensures patency and adequate oxygenation, critical in the ABCDE approach. This is the first action to prevent respiratory arrest, prioritizing airway protection before addressing bleeding or hemodynamic instability in cirrhosis.

A. Insertion of a tracheostomy with frequent suctioning B. Endotracheal intubation and mechanical ventilation C. Initiation of continuous positive airway pressure (CPAP) D. Administration of 100% O2 by non-rebreather mask

Correct Answer is B

Explanation

Choice A reason: Tracheostomy is used for long-term airway management in chronic respiratory failure or airway obstruction. A respiratory rate of 6 breaths/min and SpO2 of 88% with lethargy indicate acute respiratory failure requiring immediate ventilatory support. Tracheostomy is invasive and time-consuming, making it less suitable than intubation for acute stabilization.

Choice B reason: A respiratory rate of 6 breaths/min, SpO2 of 88%, and increasing lethargy indicate severe hypoventilation and hypoxemia, risking respiratory arrest. Endotracheal intubation with mechanical ventilation ensures airway protection and adequate gas exchange, correcting CO2 retention and hypoxemia. This is the most effective intervention for acute respiratory failure in this critical scenario.

Choice C reason: Continuous positive airway pressure (CPAP) supports breathing in patients with adequate respiratory effort, like in obstructive sleep apnea. A respiratory rate of 6 breaths/min and lethargy suggest inadequate ventilation, requiring controlled mechanical support. CPAP is non-invasive but insufficient for severe hypoventilation, making it inappropriate for this acute situation.

Choice D reason: A non Yvonne-rebreather mask delivering 100% O2 can improve hypoxemia but does not address hypoventilation (respiratory rate 6 breaths/min) or CO2 retention, which contribute to lethargy. Mechanical ventilation via intubation is needed to correct both hypoxemia and hypercapnia, making this a less effective intervention for the client’s critical condition.

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A nurse is caring for a client in the ICU with suspected cardiogenic shock following a myocardial infarction. The client has a blood pressure of 85/50 mm Hg and cool, clammy skin. Which intervention should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

A client with cirrhosis is admitted with hematemesis and tachycardia. The nurse suspects variceal bleeding. Which action should the nurse take first?

Correct Answer is D

Explanation

A client with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The client is increasingly lethargic. Which intervention will the nurse anticipate?

Correct Answer is B

Explanation

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