The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?

Oxygen saturation 92%

Skin cool and clammy

Blood pressure (BP) 92/56 mm Hg

Heart rate 118 beats/minute

Answer and Explanation

The Correct Answer is B

A. Oxygen saturation of 92% in (option A) is incorrect because While an oxygen saturation of 92% is suboptimal and may require intervention, it may not have the same immediate implications as low blood pressure. The healthcare provider should be informed, but addressing the blood pressure takes priority.
B. Skin cool and clammy in (option B) is correct because Cool and clammy skin is often associated with inadequate peripheral perfusion, which is a characteristic of septic shock.

C. Septic shock is characterized by systemic inflammation, vasodilation, and hypotension. Inadequate blood pressure is a significant concern in septic shock as it indicates poor tissue perfusion and compromised organ function. However, the mean arterial pressure is till acceptable.
D. Heart rate of 118 beats/minute in (option D) is incorrect because: Tachycardia is a common finding in septic shock and reflects the body's compensatory response to maintain cardiac output. While it is a significant finding, low blood pressure takes precedence in terms of urgency.

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Correct Answer is B

Explanation

Systemic vascular resistance represents the resistance to blood flow in the systemic circulation. It is an important indicator of afterload, which is the force against which the left ventricle must pump to eject blood into the systemic circulation. By monitoring the changes in SVR, the nurse can assess the impact of medications aimed at reducing left ventricular afterload.
A. Pulmonary artery wedge pressure (PAWP) in (option A) is incorrect because: PAWP is a measure of left ventricular preload and reflects the pressure within the left atrium and left ventricle at end-diastole. It is not specifically related to afterload reduction.
C. Pulmonary vascular resistance (PVR) in (option C) is incorrect because: PVR represents the resistance to blood flow in the pulmonary circulation. It is not directly related to left ventricular afterload.
D. Central venous pressure (CVP) in (option D) is incorrect because: CVP reflects the pressure in the right atrium and is an indicator of right-sided cardiac function. It is not specifically related to left ventricular afterload reduction.
Therefore, to assess the effectiveness of medications in reducing left ventricular afterload, the nurse should monitor the systemic vascular resistance (SVR).

A. Sterile dressing changes B. Emotional support C. Fluid resuscitation D. Range-of-motion exercises

Correct Answer is C

Explanation

In the initial 24 hours after burn injury, fluid resuscitation is a critical priority in the management of burn patients. Burn injuries can lead to significant fluid loss, both locally at the burn site and systemically due to increased capillary permeability. Fluid resuscitation aims to restore and maintain adequate intravascular volume, ensuring sufficient tissue perfusion and organ function.
The Parkland Formula is commonly used to guide fluid resuscitation in burn patients. It involves calculating the total volume of fluid needed in the first 24 hours, with a portion given in the initial hours after injury and the remainder given over the remaining hours.
A. Sterile dressing changes (option A) are incorrect because they are important in wound care management for burn patients to prevent infection. However, fluid resuscitation takes precedence within the first 24 hours.
B. Emotional support (option B) is incorrect because it is an essential aspect of burn care, as burn injuries can have a significant psychological impact. While emotional support is crucial for the patient's overall well-being, it may not be the highest priority within the first 24 hours compared to addressing the physiological needs of fluid resuscitation.
D. Range-of-motion exercises (option D) are incorrect because they are important for preventing contractures and maintaining joint mobility in burn patients. However, they are typically initiated after the initial fluid resuscitation phase and wound stabilization.
Therefore, the priority the nurse anticipates within the first 24 hours for a 31-year-old male patient with burn injuries is fluid resuscitation.

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The nurse is caring for a patient who has septic shock. Which assessment finding is most important for the nurse to report to the health care provider?

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Naxlex Comprehensive Predictor Exams

To determine the effectiveness of medications that a patient has received to reduce left ventricular afterload, which hemodynamic parameter will the nurse monitor?

Correct Answer is B

Explanation

A 31-year-old male patient with burn injuries is admitted to the burn unit. Which priority does the nurse anticipate within the first 24 hours?

Correct Answer is C

Explanation

How does the emergency department nurse caring for a critically ill with septic shock recognize that severe tissue hypoxia is present?

The nurse needs to estimate quickly the heart rate of a patient with a regular heart rhythm. Which method will be best to use?

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A 27-year-old male patient who has been involved in a motor vehicle crash is admitted to the emergency department with cool, clammy skin, tachypnoea, tachycardia, and hypotension. All of these orders are written. Which one will the nurse act on first?