What is the primary goal of nursing care for the patient who is diagnosed with any type of shock? To manage and treat:

increased cardiac output.

inadequate tissue perfusion.

fluid overload or deficit

vasoconstriction of vasculature.

Answer and Explanation

The Correct Answer is B

A) Increased cardiac output:
While cardiac output is an important factor in shock management, the primary goal of nursing care is not specifically to increase cardiac output. Shock typically involves inadequate tissue perfusion, which may be caused by a variety of factors including low cardiac output, vasodilation, or fluid imbalance. The focus of nursing care is to restore adequate perfusion to tissues, which may involve improving cardiac output as part of a larger therapeutic strategy.

B) Inadequate tissue perfusion:
The primary goal in the treatment of shock is to restore adequate tissue perfusion, as shock is defined by a failure of the circulatory system to supply sufficient oxygen and nutrients to the body's tissues and organs. Inadequate tissue perfusion can lead to organ dysfunction and, if not addressed, can result in organ failure and death. Nursing interventions are aimed at improving perfusion through fluid resuscitation, vasoactive medications, and other strategies to ensure that oxygen and nutrients are delivered to vital organs.

C) Fluid overload or deficit:
Managing fluid status is crucial in shock, as fluid imbalance (either overload or deficit) can exacerbate the condition. However, fluid overload or deficit is not the primary focus; rather, it is one aspect of managing inadequate tissue perfusion. For example, in hypovolemic shock, the nurse would manage fluid deficit, while in cardiogenic shock, the focus would be on optimizing fluid balance without causing overload.

D) Vasoconstriction of vasculature:
While vasoconstriction can be a compensatory mechanism in certain types of shock (e.g., hypovolemic shock), the primary goal is not to induce vasoconstriction per se. In some cases, vasodilation may occur (as in septic shock), and vasoconstriction could be harmful. The goal is to optimize the vascular tone and perfusion, which may involve vasodilation or vasoconstriction depending on the type of shock.

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Correct Answer is A

Explanation

A) Start fluid resuscitation and prepare for transport to a Burn Center:
In this case, the patient has burns that cover 27% of the total body surface area (TBSA), which falls within the moderate to severe range for burn injuries. Fluid resuscitation is critical to prevent hypovolemic shock, a common complication of severe burns due to fluid loss. The "rule of nines" or Lund-Browder chart can be used to calculate the amount of fluids needed. The patient should also be prepared for transport to a specialized burn center, where advanced care can be provided for wound management, infection prevention, and long-term rehabilitation.

B) Apply petroleum-based antibiotic cream to the affected areas:
Although topical antibiotics are an essential part of burn care to prevent infection, petroleum-based ointments are typically not recommended in the emergent phase of burn management. Applying such creams could potentially trap heat and cause further tissue damage, and petroleum-based products can be occlusive, which may interfere with wound healing.
C) Cover the burns with saline-soaked gauze and medicated ointment:
While it is important to keep burns covered to prevent infection, the use of saline-soaked gauze and medicated ointments are more appropriate after initial fluid resuscitation and stabilization of the patient. Immediate burn care focuses on preventing further injury and initiating fluid resuscitation. Saline-soaked gauze is typically used in a controlled setting, like in a burn unit, and the patient's wounds should not be excessively covered with ointment during the emergent phase.

D) Clean the wounds with soap and room temperature water:
In burn management, cleaning the wounds with soap and water can disrupt the skin's protective barrier, particularly in the emergent phase. It is important to gently clean the wounds with sterile saline or an antiseptic solution and avoid harsh cleansers. Soap and water might cause irritation, exacerbate pain, and increase the risk of infection. The focus should be on stabilizing the patient and initiating proper wound management with sterile techniques.

A. Packed Red Blood Cells (PRBC's) B. Platelets C. Cryoprecipitate D. Fresh Frozen Plasma (FFP)

Correct Answer is D

Explanation

A) Packed Red Blood Cells (PRBCs):
Packed Red Blood Cells are typically transfused when there is anemia or significant blood loss leading to low hemoglobin levels. In the case of warfarin overdose or elevated PT/INR, the problem is related to coagulation and not red blood cell count.

B) Platelets:
Platelets are typically transfused when there is thrombocytopenia or a need to address platelet dysfunction (e.g., in patients with bleeding due to low platelet counts). However, the elevated PT and INR in this case are related to the coagulation cascade being inhibited by warfarin, not platelet deficiency.

C) Cryoprecipitate:
Cryoprecipitate is primarily used to replace clotting factors such as fibrinogen, factor VIII, and von Willebrand factor. It is typically transfused in patients with hemophilia or bleeding disorders related to low fibrinogen levels. However, in this case, the issue is related to warfarin-induced inhibition of clotting factors (specifically the vitamin K-dependent factors: II, VII, IX, and X), not a deficiency in fibrinogen or specific clotting factors addressed by cryoprecipitate.

D) Fresh Frozen Plasma (FFP):
Fresh Frozen Plasma (FFP) is the most appropriate choice for this patient. FFP contains all the coagulation factors, including the vitamin K-dependent factors that warfarin inhibits. When a patient on warfarin presents with elevated PT and INR (which indicates impaired clotting ability), FFP is used to replace the clotting factors and help reverse the effects of warfarin.

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What is the primary goal of nursing care for the patient who is diagnosed with any type of shock? To manage and treat:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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