The emergency department nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective by finding which one of the following?

The patient's mean arterial pressure (MAP) is 50 mm Hg.

The patient's GCS score is 9.

The patient's urine output has been 35 ml over the last hour.

The patient's hemoglobin is within normal limits.

Answer and Explanation

The Correct Answer is C

Urine output is an essential indicator of renal perfusion and overall fluid status. In a patient in shock, maintaining an adequate urine output is a crucial goal of fluid resuscitation. A urine output of 0.5 to 1 mL/kg/hour is generally considered adequate in adults. The given value of 35 ml over the last hour suggests that the patient is producing urine, which indicates that fluid resuscitation is effective in restoring perfusion to the kidneys.
A. The patient's mean arterial pressure (MAP) is 50 mm Hg in (option A) is incorrect because While mean arterial pressure is an important hemodynamic parameter, a single value alone may not provide a comprehensive assessment of the patient's response to fluid resuscitation.
B. The patient's GCS score is 9 in (option B) is incorrect because The Glasgow Coma Scale (GCS) assesses the level of consciousness and neurological function but does not directly reflect fluid resuscitation effectiveness.
D. The patient's hemoglobin is within normal limits: (option D) is incorrect because Haemoglobin levels are important for assessing oxygen-carrying capacity but do not directly indicate the effectiveness of fluid resuscitation.
Therefore, the nurse can evaluate that fluid resuscitation for a 70 kg patient in shock is effective by observing a urine output of 35 ml over the last hour.

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Correct Answer is C

Explanation

Septic shock is a life-threatening condition characterized by severe infection, systemic inflammation, and inadequate tissue perfusion. In this critical situation, one of the initial priorities is to restore intravascular volume and improve tissue perfusion. Initiation of an intravenous line allows for the administration of fluids and other necessary medications to support the patient's hemodynamic stability.
While the other interventions mentioned are also important components of septic shock management, the immediate priority is to address hypotension and tissue hypoperfusion through fluid resuscitation:
A. Obtaining wound and blood cultures in (option A) is incorrect because: Cultures are important to identify the source and causative organisms of the infection. However, fluid resuscitation should take priority over obtaining cultures, as it is necessary to stabilize the patient's hemodynamics.
B. Removing or controlling potentially infected sources in (option B) is incorrect because: Identifying and controlling the source of infection is crucial in septic shock management to prevent further progression. However, initiating fluid resuscitation is more time-sensitive and should be prioritized.
D. Drawing blood for hematology and chemistry studies in (option D) is incorrect because Laboratory studies are important for evaluating organ function and guiding treatment. However, the immediate focus should be on fluid resuscitation to address the underlying hypoperfusion and stabilize the patient's condition.
Therefore, the intervention considered a priority when treating a patient who presents with septic shock is the initiation of an intravenous line and fluid administration to restore intravascular volume and improve tissue perfusion.

A. Allen's test is positive. B. The mean arterial pressure (MAP) is 90 mm Hg. C. The dicrotic notch is visible in the waveform. D. The right hand is numb.

Correct Answer is D

Explanation

Arterial pressure monitoring involves the insertion of an arterial catheter, typically in the radial artery, to directly measure blood pressure. Complications can arise from this invasive procedure, and one potential complication is inadequate blood flow to the hand, leading to numbness or ischemia.
A. The Allen's test is positive in (option A) is incorrect because The Allen's test is performed before arterial catheter insertion to assess the collateral circulation of the hand. A positive Allen test indicates adequate collateral circulation, which is desirable before performing the procedure. However, it does not directly indicate a complication during or after arterial pressure monitoring.
B. The mean arterial pressure (MAP) is 90 mm Hg in (option B) is incorrect because The mean arterial pressure (MAP) represents the average pressure in the arterial system during one cardiac cycle. While changes in MAP can be significant for patient management, it does not specifically indicate a complication of arterial pressure monitoring.
C. The dicrotic notch visible in the waveform in (option C) is incorrect because The dicrotic notch represents the closure of the aortic valve and is a normal finding in arterial waveforms. Its presence does not indicate a complication.

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The emergency department nurse evaluates that fluid resuscitation for a 70 kg patient in shock is effective by finding which one of the following?

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Naxlex Comprehensive Predictor Exams

Which of the following interventions is considered a priority when treating a patient who presents with septic shock?

Correct Answer is C

Explanation

An arterial catheter is inserted in the right radial artery to monitor a patient's blood pressure. Which information obtained by the nurse indicates that a complication of arterial pressure monitoring may be occurring?

Correct Answer is D

Explanation

What typical sign/symptom indicates the early stage of septic shock?

A 32-year-old male patient sustains 78% TBSA burn and is currently admitted to the burn unit. Which sequential order would the nurse arrange the events involved in burn shock following a patient's exposure to burns?

The nurse is caring for a patient receiving a continuous norepinephrine (Levophed) IV infusion. Which patient assessment information indicates that the infusion rate may be too high?

A 40-year-old female patient with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). The nurse suspects that the patient may be experiencing neurogenic shock in addition to hypovolemic shock, based on which one of the following?

Which assessment information obtained by the nurse when caring for a COPD patient receiving mechanical ventilation indicates the need for suctioning?

Premature ventricular contractions (PVCs) occur while the nurse is suctioning a patient's endotracheal tube. Which action by the nurse is best?

A 30-year-old female patient is admitted to the emergency department with two systemic inflammatory response syndrome variables: temperature of 100.2°F (35°C) and high blood sugar. Which intervention from the sepsis resuscitation bundle does the nurse initiate?

When assessing the hemodynamic information for a newly admitted patient in shock of unknown etiology, the emergency department nurse will anticipate the administration of large volumes of Lactated Ringers (LR) when which one of the following occurs?