A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. ordered by the health care provider should the nurse implement first?

Insert two large-bore IV catheters.

Provide oxygen at 100% per non-rebreather mask.

Draw blood to type and crossmatch for transfusions. Initiate continuous

electrocardiogram (ECG) monitoring.

Answer and Explanation

The Correct Answer is B

Cool, clammy skin, tachycardia, and hypotension are signs of shock, indicating inadequate tissue perfusion and oxygenation. The immediate priority is to ensure adequate oxygen delivery to the tissues. Providing oxygen at 100% via a non-rebreather mask helps increase the patient's oxygen saturation and improve tissue oxygenation.
While all the options mentioned are important in the management of a patient in shock, oxygenation takes priority as it directly addresses compromised tissue perfusion and oxygenation.
A. Inserting two large-bore IV catheters in (option A) is incorrect because: Establishing intravenous access is crucial for fluid resuscitation and administration of medications, but it can be done after ensuring adequate oxygenation.
C. Drawing blood to type and crossmatch for transfusions in (option C) is incorrect because Blood typing and crossmatching are important for potential blood transfusions but should not be the first action in this critical situation.
D. Initiating continuous electrocardiogram (ECG) monitoring in (option D) is incorrect because Continuous ECG monitoring is important for assessing cardiac rhythm and detecting any dysrhythmias, but ensuring oxygenation should be the initial priority.
Therefore, in a patient presenting with cool, clammy skin, tachycardia, and hypotension, the nurse should first provide oxygen at 100% via a non-rebreather mask to address inadequate tissue perfusion and oxygenation.

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Correct Answer is A

Explanation

In the early stage of septic shock, the body initiates compensatory mechanisms to combat the infection and restore adequate tissue perfusion. Tachypnoea (rapid breathing) and tachycardia (elevated heart rate) are common early signs of septic shock.
Tachypnoea occurs as a response to increased metabolic demand and to compensate for impaired oxygenation and tissue perfusion. Tachycardia is the body's attempt to maintain cardiac output and compensate for decreased blood pressure.
B. Pallor and cool skin in (option B) is incorrect because Pallor and cool skin can occur in later stages of septic shock when perfusion to the peripheral tissues is compromised. However, they are not specific to the early stage.
C. Blood pressure 84/50 mm Hg in (option C) is incorrect because A blood pressure reading of 84/50 mm Hg indicates hypotension, which is typically seen in later stages of septic shock. In the early stage, blood pressure may still be within normal or slightly decreased range.
D. Respiratory acidosis in (optionD) is incorrect because: Respiratory acidosis refers to an imbalance in acid-base status and is not specific to the early stage of septic shock. Acid-base disturbances may occur at any stage of shock but are not indicative of the early stage.

A. Cooling baths B. Blood transfusion C. 30 ml/kg of Lactated Ringers (LR) D. NPO Status

Correct Answer is C

Explanation

The sepsis resuscitation bundle typically includes the administration of intravenous fluids to restore adequate perfusion and address hypovolemia. The initial fluid of choice is often the crystalloid solution, such as Lactated Ringers (LR), and the recommended initial fluid bolus is 30 ml/kg. This intervention aims to optimize intravascular volume and improve tissue perfusion.

A. Cooling baths in (option A) is incorrect because they may be used in the management of hyperthermia or fever, but they are not specific interventions in the sepsis resuscitation bundle.

B. Blood transfusion in (option B) is incorrect it may be necessary in certain cases of sepsis, such as severe anemia or hypovolemia, but it is not a routine intervention in the sepsis resuscitation bundle based solely on the provided information.

D. NPO status (nothing by mouth) in (option D) is incorrect because it is not a specific intervention in the sepsis resuscitation bundle. It may be indicated in certain cases, such as when surgery is required or if there is a risk of aspiration, but it does not directly address the sepsis-related variables mentioned.

It is important to note that the specific management of sepsis may vary based on the patient's individual condition, clinical presentation, and healthcare provider's orders.

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A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. ordered by the health care provider should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What typical sign/symptom indicates the early stage of septic shock?

Correct Answer is A

Explanation

A 30-year-old female patient is admitted to the emergency department with two systemic inflammatory response syndrome variables: temperature of 100.2°F (35°C) and high blood sugar. Which intervention from the sepsis resuscitation bundle does the nurse initiate?

Correct Answer is C

Explanation

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