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 C
Explanation
A) Theophylline:
Theophylline is a bronchodilator medication that is used for the long-term management of asthma, but it is not typically used as the initial treatment for acute asthma exacerbations. Its onset of action is slower compared to short-acting beta agonists like albuterol.
B) Montelukast:
Montelukast is a leukotriene receptor antagonist that is used for the long-term management of asthma, but it is not typically used as the initial treatment for acute asthma exacerbations. Its onset of action is slower compared to short-acting beta agonists like albuterol.
C) Albuterol.
The patient is presenting with symptoms consistent with an asthma exacerbation, including shortness of breath, increased work of breathing, expiratory wheezing, and a history of asthma. Albuterol is a short-acting beta agonist bronchodilator commonly used as the first-line treatment for acute asthma exacerbations. It acts quickly to relax bronchial smooth muscles, relieve bronchoconstriction, and improve airflow, which can help alleviate the patient's symptoms of shortness of breath and wheezing.
D) Salmeterol:
Salmeterol is a long-acting beta agonist bronchodilator that is used for the maintenance treatment of asthma, but it is not typically used as the initial treatment for acute asthma exacerbations. Its onset of action is slower compared to short-acting beta agonists like albuterol, and it is not recommended for rapid relief of acute symptoms.
Correct Answer is ["B","D"]
Explanation
A. Diabetes: Diabetes is not typically a contraindication for decongestant use. However, patients with diabetes should be cautious with decongestants that contain sugar or other ingredients that may affect blood glucose levels.
B. Hypertension: Decongestants can cause vasoconstriction, which may lead to an increase in blood pressure. Patients with hypertension should use decongestants cautiously and under the guidance of a healthcare provider to avoid exacerbating their condition.
C. Hyperthyroidism: While decongestants can stimulate the sympathetic nervous system and may exacerbate symptoms of hyperthyroidism such as tachycardia and palpitations, hyperthyroidism is not typically considered a contraindication for decongestant use. However, patients with hyperthyroidism should use decongestants cautiously and consult with their healthcare provider.
D. Heart disease: Decongestants can increase heart rate and blood pressure, potentially exacerbating symptoms in patients with underlying heart conditions such as coronary artery disease, heart failure, or arrhythmias. Patients with heart disease should use decongestants cautiously and consult with their healthcare provider before use.
E. Allergic rhinitis: Allergic rhinitis is not typically a contraindication for decongestant use. In fact, decongestants are often used to relieve nasal congestion associated with allergic rhinitis. However, patients with allergic rhinitis should use decongestants cautiously and follow the recommended dosage instructions.
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