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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Incorrect. Patients have a legal right to access their medical records under the Health Information Portability and Accountability Act (HIPAA). Denying access is a violation of patient rights and could lead to legal consequences.

Undermines patient autonomy and trust. Patients have a right to know what information is in their medical records and to participate in their own healthcare decisions. Denying access can erode trust in the healthcare system.

Potential for errors and misunderstandings. If patients cannot review their records, they may not be able to identify errors or misunderstandings that could impact their care.

Choice B rationale:

Correct. This response upholds patient rights while ensuring that the request for access is documented and handled appropriately.

Protects patient privacy and confidentiality. The written request process helps to ensure that only the patient or their authorized representative has access to the records.

Provides a mechanism for tracking and auditing access requests. This can help to prevent unauthorized access and ensure compliance with HIPAA regulations.

Choice C rationale:

Incorrect. Patients have a right to access their records at any time, not just when they are being discharged.

Delays access to information. Patients may need to review their records to make informed decisions about their care, even if they are not being discharged.

Potential for records to be lost or misplaced. There is a risk that records could be lost or misplaced if they are not provided to the patient until discharge.

Choice D rationale:

Incorrect. Patients do not need to provide a reason for wanting to access their medical records.

Intrusive and unnecessary. Patients may feel uncomfortable or embarrassed about having to explain their reasons for wanting to access their records.

Potential for discrimination. Patients may be less likely to request access to their records if they feel that they will be judged or questioned about their reasons for doing so.

A. Auscultate for breath sounds. B. Establish an open airway. C. Establish IV access. D. Feel for a carotid pulse.

Correct Answer is B

Explanation

Establishing an open airway is the most crucial and immediate action in any respiratory arrest situation, including when a client has heart failure. Here's a detailed explanation: 1. Airway patency is paramount for survival: Oxygen, the essential element for life, cannot reach the lungs and bloodstream without a clear and unobstructed airway. Brain cells are extremely sensitive to oxygen deprivation and start to die within minutes without it, leading to irreversible brain damage or death. 2. Respiratory arrest in heart failure: Heart failure often leads to fluid buildup in the lungs (pulmonary edema), which can significantly impair breathing. Respiratory arrest can occur due to: Excessive fluid accumulation in the lungs. Weakening of respiratory muscles due to fatigue or heart failure itself. Arrhythmias or heart blocks affecting heart's ability to pump effectively. 3. Steps to establish an open airway: Head tilt-chin lift maneuver: Gently tilt the head back and lift the chin to open the airway. Jaw thrust maneuver: If a neck injury is suspected, use the jaw thrust maneuver to avoid further injury. Removal of any visible obstructions: Clear any visible foreign objects or fluids from the mouth or throat. Use of airway adjuncts: Consider using oral or nasal airways to maintain airway patency, especially if the patient is unconscious.

4. Rationale for other choices:

A. Auscultating for breath sounds: While important for assessment, it does not address the immediate need to establish airflow.

C. Establishing IV access: IV access is necessary for medications and fluids, but airway takes priority in respiratory arrest.

D. Feeling for a carotid pulse: Checking for a pulse is essential, but only after ensuring an open airway and attempting to restore breathing.

5. Importance of prioritizing airway: Establishing an open airway allows for potential rescue breaths and ventilation, which can help restore oxygen levels and prevent further deterioration. Even if a pulse is present, without a clear airway, oxygen cannot reach the vital organs, leading to organ failure and death.

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Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is caring for a patient who requests to review his medical record. How should the nurse respond?

Correct Answer is B

Explanation

A nurse is caring for a client who has heart failure and respiratory arrest. What should be the nurse’s first action?

Correct Answer is B

Explanation

A nurse on the unit suspects that a colleague is extracting a small quantity of morphine from the syringe prior to administering it to the patient.What should the nurse do in this situation?

In a post-surgical unit, the nurse cares for many patients experiencing pain. Which situation is likely to lower a patient’s pain threshold?

A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client’s temperature.Which of the following findings should the nurse identify as an indication that the client is dehydrated?

During a shift change report, a nurse notices that a patient’s IV bag of 0.9% sodium chloride has 900 mL of fluid remaining.The nurse checks again 30 minutes later and finds that the IV bag is empty. What should the nurse do in this situation?

A nurse notes a small section of bowel protruding from the abdominal incision of a client who is postoperative. After calling for assistance, which of the following actions should the nurse take first?

A nurse is assessing a patient with a surgical wound healing by secondary intention. Which finding should the nurse report to the charge nurse?

A nurse is caring for a patient who has acute kidney injury.The patient’s ABGs are: pH: 7.26, PaCO2: 30 mm Hg, HCO3: 14 mEq/L. Which of the following acid-base imbalances should the nurse identify the patient is experiencing?

A nurse is providing care for a patient who is three days postoperative following a cholecystectomy. The nurse suspects an infection due to the yellow and thick drainage from the dressing.What type of drainage should the nurse report?