A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to
obtain the blood pressure.
Check the level of consciousness.
administer oxygen.
obtain a 12-lead electrocardiogram (ECG).
The Correct Answer is B
Assessing the patient's level of consciousness is a critical initial step in evaluating a patient with shock. Altered mental status or decreased level of consciousness can be indicative of inadequate cerebral perfusion and may require immediate interventions to address compromised brain function and ensure patient safety.
While all the options mentioned are important in the assessment and management of a patient in shock, checking the level of consciousness takes priority as it provides essential information about the patient's neurological status and helps guide further interventions.
A. Obtaining the blood pressure in (option A) is incorrect because Assessing blood pressure is crucial in evaluating a patient in shock, but it can be done in conjunction with checking the level of consciousness and other vital signs.
C. Administering oxygen in (option C) is incorrect because: Administering oxygen is important in managing shock, as tissue hypoxia is a key concern. However, it can be done simultaneously with assessing the level of consciousness and initiating other interventions.
D. Obtaining a 12-lead electrocardiogram (ECG) in (option D) is incorrect because While an ECG may provide valuable information about the patient's cardiac function, it is not the first priority in a patient with shock of unknown etiology. Assessing the level of consciousness and vital signs takes precedence.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Neurogenic shock is a type of distributive shock that occurs due to the loss of sympathetic nervous system tone after a spinal cord injury or other traumatic brain injuries. This loss of sympathetic tone leads to vasodilation and decreased systemic vascular resistance, resulting in inadequate perfusion to vital organs.
One of the hallmark signs of neurogenic shock is bradycardia (a heart rate less than 60 beats/min) due to the unopposed parasympathetic activity. The parasympathetic system becomes dominant when sympathetic activity is impaired. Therefore, a heart rate of 48 beats/min in this patient suggests the possibility of neurogenic shock.
A. Cool, clammy skin in (option A) is incorrect because Cool, clammy skin is a characteristic of hypovolemic shock, where reduced blood volume leads to vasoconstriction to redirect blood flow to vital organs.
B. BP of 82/40 mm Hg in (option B) is incorrect because: Hypotension is a common finding in both neurogenic shock and hypovolemic shock. A low blood pressure reading alone does not specifically indicate neurogenic shock.
D. Shortness of breath in (option D) is incorrect because Shortness of breath is not specific to neurogenic shock but can occur in various types of shock, including hypovolemic shock. It may result from inadequate oxygenation or impaired respiratory function due to the underlying condition or associated injuries.
Therefore, the heart rate of 48 beats/min suggests the possibility of neurogenic shock in addition to hypovolemic shock in this patient.
Correct Answer is C
Explanation
The nurse should listen over both lung fields to ensure that air entry is present bilaterally, indicating that the tube is correctly positioned in the trachea. This comes after observing chest movements.
B. Using an end-tidal CO2 monitor to check for placement in the trachea in (option B) is incorrect because End-tidal CO2 monitoring can provide confirmation of correct tube placement in the trachea by detecting exhaled CO2 levels. However, it requires additional equipment and setup, which may not be readily available at the bedside or immediately accessible.
C. Observing the chest for symmetrical movement with ventilation is the initial action after placing an endotracheal tube.
D. Obtaining a portable chest radiograph to check tube placement (option D) is incorrect because Chest radiographs are commonly used to confirm endotracheal tube placement, especially for long-term confirmation or if there are concerns about placement. However, obtaining a portable chest radiograph may involve delays and is not the initial action to be taken for immediate verification.
Therefore, the best initial action by the nurse to verify the correct placement of an endotracheal tube (ET) after insertion is to auscultate for the presence of bilateral breath sounds.
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