In the plan of care, the most important intervention for a patient experiencing shock is assessing:
Respirations rate.
Heart rate.
Blood pressure.
Temperature.
The Correct Answer is C
A) Respirations rate:
Respiratory rate is an important vital sign to monitor in patients with shock, as respiratory distress can indicate inadequate oxygenation. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.
B) Heart rate:
Heart rate is an important vital sign to monitor in patients with shock, as tachycardia (rapid heart rate) may indicate the body's compensatory response to maintain cardiac output and tissue perfusion. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.
C) Blood pressure.
In shock, the body's vital organs are not receiving adequate blood flow and oxygen, leading to a life-threatening condition. While all vital signs are important to monitor in a patient experiencing shock, blood pressure is typically considered the most critical because it reflects the perfusion pressure—the force driving blood through the circulatory system to deliver oxygen and nutrients to the body's tissues. A decrease in blood pressure can indicate inadequate tissue perfusion and impending organ failure. Therefore, timely assessment and monitoring of blood pressure are essential for identifying and managing shock effectively.
D) Temperature:
Temperature monitoring is important in assessing for signs of infection or other systemic issues that may contribute to shock, such as sepsis. However, blood pressure is generally considered more critical to assess initially in the context of shock because it directly reflects tissue perfusion and oxygen delivery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) This is normal.
Guaifenesin is an expectorant medication commonly used to help loosen and thin mucus in the airways, making it easier to cough up. Coughing up phlegm after taking guaifenesin is an expected response and indicates that the medication is working as intended. Guaifenesin helps to clear the airways of excess mucus, which can be particularly beneficial for individuals with respiratory conditions such as bronchitis or chest congestion.
B) This requires further investigation.
Coughing up phlegm after taking guaifenesin is a common and expected response and does not typically indicate a need for further investigation unless there are other concerning symptoms present. It is important for the nurse to provide reassurance and education about the expected effects of the medication.
C) This is indicative of an allergic reaction.
Coughing up phlegm after taking guaifenesin is not indicative of an allergic reaction. Allergic reactions to guaifenesin are rare but may include symptoms such as rash, itching, swelling, dizziness, or difficulty breathing. If the client were experiencing these symptoms, it would be important to assess further for a possible allergic reaction and intervene accordingly.
D) This means there is probably more pathology present.
Coughing up phlegm after taking guaifenesin does not necessarily indicate the presence of more pathology. It simply indicates that the medication is helping to loosen and mobilize mucus in the airways, which is a normal response to expectorant therapy. If the client has concerns about their symptoms, further assessment by a healthcare provider may be warranted, but coughing up phlegm alone is not necessarily indicative of worsening pathology.
Correct Answer is A
Explanation
A) A stuffed animal.
Stuffed animals are often considered one of the most appropriate gifts for hospitalized children. They provide comfort, companionship, and a sense of security during a stressful and unfamiliar time. Stuffed animals can serve as cuddly companions for the child, offering emotional support and helping to alleviate anxiety and loneliness while in the hospital.
B) A plant:
While plants can brighten up a hospital room and add a touch of nature, they may not be the most suitable gift for a hospitalized child. Plants require care and maintenance, which may not be feasible or practical in a hospital setting. Additionally, some hospitals have restrictions on bringing plants into patient rooms due to concerns about allergies or infection control.
C) Flowers:
Flowers are a common gift to brighten someone's day, but they may not be the best choice for a hospitalized child. Some hospitals have policies restricting flowers in patient rooms due to concerns about pollen allergies and infection control. Additionally, flowers have a limited lifespan and require regular maintenance, which may not be practical in a hospital environment.
D) A book:
While reading can be a great way to pass the time and provide entertainment for a hospitalized child, it may not be the most appropriate gift in all cases. The child's age, interests, and current health status should be considered when selecting a book. Additionally, some children may not be in the mood for reading if they are feeling unwell or fatigued. A stuffed animal offers more immediate comfort and companionship.
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