The nurse gets hand-off report on four patients. Which patient would the nurse assess first?

Patient with urine output of 40 mL/hr for the last hour.

Patient with a blood pressure change of 128/74 to 110/88 mmHg.

Patient with oxygen saturation maintained at 94%.

Patient with a pulse change of 100 to 88 beats/min.

Answer and Explanation

The Correct Answer is B

Choice A reason: A urine output of 40 mL/hr is within the acceptable range, as normal urine output is typically around 30-50 mL/hr. While it should be monitored, it does not indicate an immediate life-threatening issue requiring urgent assessment.

Choice B reason: A blood pressure change from 128/74 to 110/88 mmHg may indicate potential hemodynamic instability. Although the systolic blood pressure has decreased, the diastolic pressure has increased, which can be concerning. This patient may be at risk for developing more significant blood pressure changes or other complications, making this situation the highest priority for assessment.

Choice C reason: An oxygen saturation level of 94% is generally considered acceptable. While it is on the lower end of the normal range, it does not indicate an immediate life-threatening condition. Continuous monitoring is important, but it is not the most urgent situation compared to the blood pressure change.

Choice D reason: A pulse change from 100 to 88 beats/min represents a decrease in heart rate but remains within the normal range for adult heart rate (60-100 beats/min). While this change should be noted and monitored, it is not as urgent as the blood pressure change that may indicate hemodynamic instability.

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Correct Answer is B

Explanation

Choice A reason: Increasing the rate of IV fluid administration is not the priority action in this situation. Although maintaining adequate fluid levels is important for patients with traumatic brain injuries, the symptoms described (pulse change, increased pulse pressure, and respiratory irregularities) indicate that the patient may be experiencing increased intracranial pressure (ICP). Fluid administration alone will not address this issue and could potentially worsen the condition if not managed carefully.

Choice B reason: The priority action is to notify the provider immediately. The changes in vital signs (decreased pulse, increased pulse pressure, and respiratory irregularities) suggest that the patient may be experiencing increased intracranial pressure (ICP), which is a medical emergency. Immediate notification of the provider is essential for timely intervention to prevent further neurological damage or complications.

Choice C reason: Preparing to give IV pain medication is not the priority in this situation. While managing pain is important, the patient's vital sign changes indicate a more serious underlying issue (potential increased intracranial pressure) that requires immediate medical attention. Pain medication alone will not address the root cause of the symptoms.

Choice D reason: Notifying respiratory therapy for a breathing treatment is not the priority action in this scenario. Although respiratory irregularities are present, the vital sign changes suggest that the patient is experiencing increased intracranial pressure. This requires immediate medical intervention by the provider to manage the underlying condition, rather than solely focusing on respiratory support.

A. Neurogenic shock. B. Febrile seizures. C. Esophageal varices. D. Acute Respiratory Distress Syndrome.

Correct Answer is D

Explanation

Choice A reason: Neurogenic shock is a type of distributive shock that occurs due to a sudden loss of sympathetic nervous system signals to the smooth muscle in vessel walls. It is not a direct complication of septic shock, which is primarily caused by severe infection and systemic inflammation. While both are forms of shock, the mechanisms and causes are different.

Choice B reason: Febrile seizures are typically seen in children with high fevers and are not a common complication of septic shock in adults. Septic shock involves severe infection and systemic inflammatory response, leading to complications such as organ failure rather than febrile seizures.

Choice C reason: Esophageal varices are enlarged veins in the esophagus that can bleed, often seen in patients with liver disease and portal hypertension. They are not a complication of septic shock. While severe infection and systemic inflammation can lead to various complications, esophageal varices are specifically related to liver pathology.

Choice D reason: Acute Respiratory Distress Syndrome (ARDS) is a severe complication that the nurse should remain alert for in patients with septic shock. ARDS is characterized by rapid onset of widespread inflammation in the lungs, leading to respiratory failure. It is a common and serious complication of septic shock due to the systemic inflammatory response affecting the lung tissue. Early recognition and management are crucial for improving patient outcomes.

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The nurse gets hand-off report on four patients. Which patient would the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has a traumatic brain injury. The nurse assesses the following: Pulse change from 82 to 60 beats/min, Pulse pressure increase from 26 to 40 mm Hg, and Respiratory irregularities. What action by the nurse takes priority?

Correct Answer is B

Explanation

In a patient with septic shock, which complication will the nurse remain alert for?

Correct Answer is D

Explanation

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