A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?

Insert an oropharyngeal airway.

Perform the jaw thrust maneuver.

Perform endotracheal intubation.

Perform a cricothyroidotomy.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Inserting an oropharyngeal airway is used to maintain patency in patients who still have some spontaneous breathing but are at risk of airway obstruction, such as those who are unconscious. It is not sufficient for a patient who cannot maintain respirations.
B. The jaw thrust maneuver is an emergency technique used to open the airway in trauma patients with suspected cervical spine injury. It is temporary and supportive, not definitive management for respiratory failure.
C. Endotracheal intubation is the definitive airway intervention for patients who cannot maintain spontaneous respirations. It secures the airway, allows mechanical ventilation, and ensures adequate oxygenation and ventilation. This is the most appropriate intervention in respiratory insufficiency.
D. Cricothyroidotomy is an emergency surgical airway performed when endotracheal intubation is impossible, such as in severe facial trauma or upper airway obstruction. It is not the first-line approach if standard intubation is feasible.

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Correct Answer is D

Explanation

Rationale:
A. Increased urine output is not expected in the compensatory stage of shock. Early in shock, the body activates the renin-angiotensin-aldosterone system to conserve fluid, resulting in decreased urine output (oliguria).

B. Decreased heart rate is not typical in compensatory shock. The body usually responds to early hypovolemia with tachycardia to maintain cardiac output and perfusion to vital organs.

C. Hyperactive bowel sounds are not a hallmark of early shock. In fact, perfusion to the gastrointestinal system is reduced during shock, which may lead to hypoactive or diminished bowel sounds.

D. Cool, clammy skin is an expected finding in the compensatory stage of shock. The body shunts blood away from the skin and non-vital organs to maintain perfusion of vital organs (brain, heart, lungs). Peripheral vasoconstriction reduces skin perfusion, causing the skin to feel cool and moist due to sympathetic nervous system activation and increased catecholamines.

A. 3,000 ml B. 2,500 ml C. 2,000 ml D. 3,500 ml

Correct Answer is B

Explanation

Rationale:

A. 3,000 ml – This overestimates the volume for the first 8 hours.

B. 2,500 ml – This represents half of the 24-hour fluid requirement, appropriate for the first 8 hours.

The Parkland formula is used to calculate fluid resuscitation in the first 24 hours after a burn:

Total fluid requirement (ml) = 4 × body weight (kg) × % TBSA burned

Once the total 24-hour fluid requirement is calculated:

Half of the total fluid is given in the first 8 hours post-injury.
The remaining half is given over the next 16 hours.

In this scenario:

Mr. Paul’s total 24-hour fluid requirement is 5,000 ml.
Half of 5,000 ml = 2,500 ml, which should be administered in the first 8 hours after the burn occurred.

Timing calculation:

Burn occurred at 2:00 p.m.
First 8 hours after the burn: 2:00 p.m. → 10:00 p.m.
Therefore, by 10:00 p.m., Mr. Paul should have received 2,500 ml of lactated Ringer’s.

C. 2,000 ml – This underestimates the volume required in the first 8 hours.

D. 3,500 ml – This exceeds the volume for the first 8 hours and could lead to fluid overload.

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A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?

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Naxlex Comprehensive Predictor Exams

The emergency nurse is admitting a patient experiencing a GI bleed who is believed to be in the compensatory stage of shock. What assessment finding would be most consistent with the early stage of compensation?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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