ANS: ABecause patients in the early stage of septic shock have warm and dry skin, the patient’s cool and clammy skin indicates that shock is progressing. The other information will also be reported, but does not indicate deterioration of the patient’s status.DIF: Cognitive Level: Analyze (analysis) REF: 1594OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity18. A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be toa. obtain the blood pressure.b. check the level of orientation.c. administer supplemental oxygen.d. obtain a 12-lead electrocardiogram.ANS: CThe initial actions of the nurse are focused on the ABCs—airway, breathing, and circulation—and administration of O2 should be done first. The other actions should be accomplished as rapidly as possible after providing O2.DIF: Cognitive Level: Analyze (analysis) REF: 1597OBJ: Special Questions: Prioritization TOP: Nursing Process: ImplementationMSC: NCLEX: Physiological Integrity19. During change-of-shift report, the nurse is told that a patient has been admitted with dehydration and hypotension after having vomiting and diarrhea for 4 days. Which finding is most important for the nurse to report to the health care provider?a. New onset of confusion c. Heart rate 112 beats/minb. Decreased bowel sounds d. Pale, cool, and dry extremitiesANS: AThe changes in mental status are indicative that the patient is in the progressive stage of shockand that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.DIF: Cognitive Level: Analyze (analysis) REF: 1597OBJ: Special Questions: Prioritization TOP: Nursing Process: AssessmentMSC: NCLEX: Physiological Integrity20. A patient who has been involved in a motor vehicle crash arrives in the emergency department(ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention ordered by the health care provider should the nurse implement first?a. Insert two large-bore IV catheters.b. Provide O2 at 100% per non-rebreather mask.c. Draw blood to type and crossmatch for transfusions.d. Initiate continuous electrocardiogram (ECG) monitoring.ANS: B
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