Author Question: A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first ... (Read 52 times)

karlynnae · **on:** Jun 25, 2018

A patient is admitted to the emergency department (ED) for shock of unknown etiology. The first action by the nurse should be to

a. administer oxygen.
b. obtain a 12-lead electrocardiogram (ECG).
c. obtain the blood pressure.
d. check the level of consciousness.

Question 2

A patient with septic shock has a BP of 70/46 mm Hg, pulse 136, respirations 32, temperature 104 F, and blood glucose 246 mg/dL. Which intervention ordered by the health care provider should the nurse implement first?

a. Give normal saline IV at 500 mL/hr.
b. Give acetaminophen (Tylenol) 650 mg rectally.
c. Start insulin drip to maintain blood glucose at 110 to 150 mg/dL.
d. Start norepinephrine (Levophed) to keep systolic blood pressure >90 mm Hg.

amy.lauersdorf90 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The initial actions of the nurse are focused on the ABCsairway, breathing, and circulationand administration of oxygen should be done first. The other actions should be accomplished as rapidly as possible after oxygen administration.

Answer to Question 2

ANS: A
Because of the low systemic vascular resistance (SVR) associated with septic shock, fluid resuscitation is the initial therapy. The other actions also are appropriate, and should be initiated quickly as well.