The client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: T: 95° F and high white blood cell count. What is the priority of care for the patient?

Antibiotics

Blood transfusion

Warming measures

NPO status

Answer and Explanation

The Correct Answer is A

Rationale:
A. Antibiotics are correct because the patient exhibits two SIRS criteria (hypothermia and leukocytosis), which may indicate a systemic inflammatory response potentially due to infection. Early initiation of broad-spectrum antibiotics is critical to treat underlying infection and prevent progression to sepsis, which can rapidly become life-threatening.

B. Blood transfusion is incorrect because there is no indication of anemia or significant blood loss in this scenario. Transfusion does not address the primary concern of potential infection and systemic inflammation.

C. Warming measures are incorrect as the first priority. While the patient is hypothermic (T: 95° F), treating hypothermia alone does not address the underlying cause of SIRS, which could be infection or sepsis. Warming can be applied after stabilizing the patient and initiating treatment.

D. NPO status is incorrect because fasting is not a priority intervention for SIRS or suspected infection. Nutritional management may be considered later depending on the patient’s overall status, but it does not treat the immediate risk.

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Correct Answer is D

Explanation

Rationale:
A. Preventing infarcts or emboli is not the primary purpose of vasoactive medications. While some anticoagulants may reduce clot formation, vasoactive drugs are focused on hemodynamic support, not clot prevention.

B. Limiting stroke volume and cardiac output is counterproductive in shock. Shock occurs due to inadequate tissue perfusion, and decreasing cardiac output would worsen hypoperfusion and organ dysfunction.

C. Preventing pulmonary and peripheral edema is a secondary concern. While careful fluid management and some medications can reduce edema, vasoactive agents do not primarily target fluid accumulation.

D. The primary goal of vasoactive medications (such as dopamine, norepinephrine, or phenylephrine) is to maintain adequate mean arterial pressure (MAP) to ensure perfusion of vital organs. In shock, blood pressure may fall due to hypovolemia, vasodilation, or cardiac dysfunction. Vasoactive drugs constrict blood vessels and/or increase cardiac output, supporting MAP and improving tissue oxygen delivery. Maintaining an adequate MAP (usually ≥65 mm Hg) is crucial to prevent organ ischemia and progression to multi-organ failure.

A. Increase afterload B. Decrease afterload C. Increase preload D. Decrease preload

Correct Answer is C

Explanation

Rationale:
A. Increasing afterload (the resistance the heart must pump against) is not the priority in this patient. In hypovolemic or cardiogenic shock due to trauma, increasing afterload could further strain cardiac output and worsen tissue perfusion.

B. Decreasing afterload is sometimes used in cases of heart failure to reduce cardiac workload, but in acute traumatic shock with hypotension, afterload reduction could further lower perfusion pressure and is not the primary goal.

C. The primary goal in a patient with hypotension and tachycardia following chest trauma is to increase preload (the volume of blood returning to the heart). Gunshot wounds to the chest can cause hemorrhagic shock, leading to decreased circulating blood volume. Restoring preload through rapid fluid resuscitation or blood products helps increase stroke volume and cardiac output, improving blood pressure, oxygen delivery, and perfusion of vital organs.

D. Decreasing preload would worsen hypotension and compromise organ perfusion. Reducing venous return in a patient already hypovolemic is contraindicated.

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The client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: T: 95° F and high white blood cell count. What is the priority of care for the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The critical care nurse is preparing to initiate an infusion of a vasoactive medication to a patient in shock. The nurse knows that vasoactive medications are given in all forms of shock. What is the primary goal of this aspect of treatment?

Correct Answer is D

Explanation

An adult patient presents to the ED with a gunshot wound to the chest. VS: BP 90/50; HR 120; RR 24; SpO2 86%. When anticipating treatment for this patient, the nurse recognizes the primary goal of treatment is to:

Correct Answer is C

Explanation

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