A patient with new third-degree burns over 60% of the body is confused and presents with a blood pressure of 79/56 mm Hg, heart rate of 132 beats/min, and respirations of 28 breaths/min with crackles on auscultation.
The patient’s body temperature is 76° F, and the skin is pale and clammy. Which stage of shock is this patient experiencing?
Irreversible.
End-organ dysfunction.
Early reversible.
Preshock.
The Correct Answer is C
Choice A rationale:
Irreversible shock is the final stage of shock, where the body's compensatory mechanisms have failed, and damage to vital organs is irreversible. This stage is characterized by:
Profound hypotension (systolic blood pressure persistently below 60 mmHg) Severely altered mental status (unresponsiveness or coma)
Widespread organ failure (kidney failure, liver failure, respiratory failure) Lack of response to aggressive fluid resuscitation and vasopressor therapy
The patient in the question does not exhibit all of these signs and symptoms, particularly the profound hypotension and irreversible organ failure. Therefore, irreversible shock is not the most likely stage.
Choice B rationale:
End-organ dysfunction is a stage of shock where inadequate tissue perfusion has begun to cause damage to vital organs. This stage is characterized by:
Hypotension that may respond to fluid resuscitation
Signs of organ dysfunction, such as decreased urine output, altered mental status, or respiratory distress
The patient in the question does have some signs of organ dysfunction, such as confusion and crackles on lung auscultation. However, the hypotension is not as severe as typically seen in end-organ dysfunction shock, and there is no mention of other organ dysfunction like decreased urine output. Therefore, end-organ dysfunction is not the most likely stage.
Choice C rationale:
Early reversible shock is the initial stage of shock, where the body's compensatory mechanisms are still able to maintain blood pressure and organ perfusion. This stage is characterized by:
Mild to moderate hypotension Tachycardia
Cool, clammy skin Narrowed pulse pressure Restlessness or anxiety
The patient in the question presents with all of these signs and symptoms, making early reversible shock the most likely stage.
Choice D rationale:
Preshock is a state of impending shock, where the body's compensatory mechanisms are activated but not yet fully effective. This stage is characterized by:
Normal or slightly low blood pressure Tachycardia
Cool, clammy skin Restlessness or anxiety
The patient in the question has hypotension, which is not consistent with preshock. Therefore, preshock is not the correct stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["50"]
Explanation
Here are the steps to calculate the gtt/min for the manual IV infusion:
Step 1: Convert the infusion time from hours to minutes. 8 hours x 60 minutes/hour = 480 minutes
Step 2: Divide the total volume of fluid (in mL) by the infusion time in minutes to get the mL/min rate. 400 mL ÷ 480 minutes = 0.8333 mL/min
Step 3: Multiply the mL/min rate by the drop factor (gtt/mL) to get the gtt/min rate. 0.8333 mL/min x 60 gtt/mL = 50 gtt/min
Therefore, the nurse should set the manual IV infusion to deliver 50 gtt/min.
Correct Answer is D
Explanation
Choice A rationale:
It is not necessary to remind a patient to avoid turning from side to side after femoral artery catheterization. Restricting movement in this way could actually increase the risk of complications such as deep vein thrombosis (DVT).
Early ambulation is generally encouraged to promote circulation and prevent blood clots.
Patients are typically allowed to turn and reposition themselves as needed for comfort, unless there are specific contraindications.
Choice B rationale:
Keeping the patient in a high-Fowler's position for 6 hours is not a standard recommendation following femoral artery catheterization.
The patient's position should be based on their individual needs and comfort level.
In some cases, a slight elevation of the head of the bed may be helpful to promote venous return, but prolonged high-Fowler's positioning is not necessary.
Choice C rationale:
Passive range-of-motion exercises are not typically performed on the affected extremity immediately following femoral artery catheterization.
This is because there is a risk of dislodging the catheter or causing bleeding at the puncture site.
Once the catheter has been removed and the puncture site has healed, gentle range-of-motion exercises may be recommended to help maintain joint mobility.
Choice D rationale:
Checking pedal pulses every 15 minutes is essential to assess for adequate circulation to the lower extremities following femoral artery catheterization.
This is because there is a risk of complications such as thrombosis or embolism, which can compromise blood flow to the legs and feet.
If the pedal pulses are weak or absent, it could indicate a serious problem that requires immediate intervention.
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