A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first?

Administer morphine sulfate 4 mg IV.

Give acetaminophen (Tylenol) 650 mg.

Infuse normal saline bolus

Draw complete blood count and coagulation studies.

Answer and Explanation

The Correct Answer is C

Rationale:
A. Administer morphine sulfate 4 mg IV is incorrect as the first intervention because while pain management is important, severe hypotension takes priority. Administering opioids before stabilizing blood pressure could worsen hypotension and perfusion.

B. Give acetaminophen (Tylenol) 650 mg is incorrect because fever reduction is secondary to stabilizing circulation. Acetaminophen does not address the patient’s life-threatening hypotension.

C. Infuse normal saline bolus is correct because the patient is hypotensive (BP 82/40), indicating circulatory compromise, which requires immediate fluid resuscitation to restore perfusion to vital organs. In the context of possible DIC, hypotension may reflect sepsis or ongoing hemorrhage, making fluid resuscitation the first priority according to the ABCs and primary survey principles.

D. Draw complete blood count and coagulation studies is incorrect as the first intervention because while laboratory evaluation is important to confirm DIC and guide treatment, it does not immediately address life-threatening hypotension. Labs can be drawn after initial stabilization.

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Correct Answer is A

Explanation

Rationale:
A. The patient exhibits signs of compensatory (early) shock, including tachycardia to maintain cardiac output, normal blood pressure due to vasoconstriction, cold and clammy skin from peripheral vasoconstriction, and decreased bowel sounds from shunting blood away from the gastrointestinal tract. During this stage, the body is actively compensating to maintain perfusion to vital organs despite underlying circulatory compromise.

B. Progressive stage of shock occurs when compensatory mechanisms fail. Hallmarks include hypotension, worsening tachycardia, rapid shallow respirations, mental status changes, oliguria, and worsening acidosis. This patient still has a normal blood pressure, indicating that shock has not yet progressed to this stage.

C. Predicting stabilization and discharge is inappropriate. Although the patient is in the early stage, septic shock can progress rapidly without prompt intervention. Immediate monitoring and treatment are required to prevent progression to progressive or refractory shock.

D. The refractory stage of shock represents irreversible organ failure despite aggressive interventions. Clinical signs include severe hypotension, profound hypoperfusion, and multi-organ dysfunction. This patient has not reached this stage, as blood pressure is still maintained and organ systems have not failed.

A. Insert an oral airway to prevent aspiration and to protect the airway. B. Offer the patient an emesis basin so that you can measure the amount of emesis. C. Prepare to suction the oropharynx while maintaining cervical spine immobilization. D. Send a specimen of the emesis to the laboratory for analysis of blood alcohol content.

Correct Answer is C

Explanation

Rationale:
A. Inserting an oral airway is not the most appropriate intervention in this situation. In a trauma patient with a possible cervical spine injury, placing an oral airway without strict spinal precautions could worsen spinal damage. In addition, oral airways are generally reserved for patients who are unconscious and lack a gag reflex; this patient is actively vomiting and may still have protective airway reflexes.

B. Offering an emesis basin does not address the primary concern of airway protection. In a trauma patient with suspected intoxication and possible head injury, the risk of aspiration is high, and simply measuring emesis does not prevent airway compromise.

C. Preparing to suction the oropharynx while maintaining cervical spine immobilization is the most appropriate intervention. Vomiting poses an immediate risk of airway obstruction and aspiration. Because the patient experienced a traumatic fall, cervical spine injury must be assumed until ruled out. Suctioning clears vomitus from the airway while spinal precautions protect against further injury, addressing the highest priority in emergency care.

D. Sending emesis to the laboratory for blood alcohol analysis is not a priority during the acute phase of trauma management. Airway protection and spinal stabilization take precedence over diagnostic testing.

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A patient with possible disseminated intravascular coagulation arrives in the emergency department with a blood pressure of 82/40, temperature 102° F (38.9° C), and severe back pain. Which physician order will the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

You have just admitted a patient to the ED following a fall from a first floor hotel balcony. The patient is 22 years old and smells of alcohol. The patient begins to vomit in the ED. Which of the following interventions is most appropriate?

Correct Answer is C

Explanation

A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?

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