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 B

Explanation

Choice A reason: IV mannitol reduces intracranial pressure by drawing fluid from brain tissue, but it requires a provider’s order and time to act. ICP of 22 mm Hg is elevated, and elevating the head of the bed is a non-invasive, immediate intervention to promote venous drainage, making it the priority action.

Choice B reason: An ICP of 22 mm Hg indicates elevated intracranial pressure, risking brain herniation. Elevating the head of the bed to 30 degrees promotes cerebral venous drainage, reducing ICP immediately. This non-invasive intervention aligns with the ABCDE approach’s focus on preventing neurological deterioration, making it the first action in traumatic brain injury management.

Choice C reason: Seizure prophylaxis prevents complications in traumatic brain injury but does not directly address elevated ICP (22 mm Hg). Seizures increase ICP further, but immediate pressure reduction is critical to prevent herniation. Head elevation is a faster, non-invasive intervention, making seizure prophylaxis secondary in this acute scenario.

Choice D reason: Increasing sedation controls agitation, which can raise ICP, but it risks respiratory depression and requires careful monitoring. ICP of 22 mm Hg needs immediate reduction, and head elevation promotes venous drainage without delay. Sedation is a supportive measure, making it less urgent than positioning to lower ICP.

A. Hypercapnia with respiratory alkalosis B. Pulmonary hypertension C. Severe hypoxemia despite supplemental oxygen D. Pleural effusion

Correct Answer is C

Explanation

Choice A reason: Hypercapnia with respiratory alkalosis is not typical in ARDS. ARDS primarily causes severe hypoxemia due to alveolar damage and impaired gas exchange. Hypercapnia (elevated CO2) may occur in advanced respiratory failure, but respiratory alkalosis is more associated with hyperventilation in early stress responses, not ARDS’s hallmark of refractory hypoxemia.

Choice B reason: Pulmonary hypertension can develop in ARDS due to hypoxic vasoconstriction and vascular remodeling from inflammation, but it is not the primary or most common symptom. ARDS is characterized by diffuse alveolar damage leading to severe hypoxemia, with pulmonary hypertension being a secondary complication rather than the defining clinical feature.

Choice C reason: Severe hypoxemia despite supplemental oxygen is the hallmark of ARDS. It results from alveolar flooding, surfactant loss, and ventilation-perfusion mismatch, impairing oxygen diffusion. Even high-flow oxygen fails to correct low PaO2 due to shunting and non-functional alveoli, making this the most common and critical symptom requiring urgent intervention.

Choice D reason: Pleural effusion is not a primary feature of ARDS. It may occur in conditions like heart failure or infection but is less common in ARDS, which primarily involves alveolar edema and inflammation. The dominant clinical issue in ARDS is severe hypoxemia due to impaired gas exchange, not fluid accumulation in the pleural space.

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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 nurse is caring for a client with a traumatic brain injury in the ICU. The client’s intracranial pressure (ICP) is 22 mm Hg. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

Which of the following is a clinical symptom most commonly associated with Acute Respiratory Distress Syndrome (ARDS)?

Correct Answer is C

Explanation

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