Author Question: During change-of-shift report, the nurse is told that a patient has been admitted with dehydration ... (Read 78 times)

ghost! · **on:** Jun 25, 2018

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
b. Heart rate 112 beats/minute
c. Decreased bowel sounds
d. Pale, cool, and dry extremities

Question 2

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. Initiate continuous electrocardiogram (ECG) monitoring.
c. Provide oxygen at 100 per non-rebreather mask.
d. Draw blood to type and crossmatch for transfusions.

kxciann · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: A
The changes in mental status are indicative that the patient is in the progressive stage of shock and that rapid intervention is needed to prevent further deterioration. The other information is consistent with compensatory shock.

Answer to Question 2

ANS: C
The first priority in the initial management of shock is maintenance of the airway and ventilation. ECG monitoring, insertion of IV catheters, and obtaining blood for transfusions should also be rapidly accomplished but only after actions to maximize oxygen delivery have been implemented.