Author Question: The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing action? ... (Read 100 times)

bclement10 · **on:** Jun 28, 2018

The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing action?

a. Place the child on a cardiac monitor.
b. Obtain arterial blood gases.
c. Provide supplemental oxygen.
d. Put the child in the Trendelenburg position.

Question 2

What explains physiologically the edema formation that occurs with burns?

a. Vasoconstriction
b. Reduced capillary permeability
c. Increased capillary permeability
d. Diminished hydrostatic pressure within capillaries

leannegxo · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: C
The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need for intubation. Cardiac monitoring would be indicated to assess the child's status further, but ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available. The Trendelenburg position is not indicated and is detrimental to the child. The head-down position increases intracranial pressure and decreases diaphragmatic excursion and lung volume.

Answer to Question 2

ANS: C
With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hours later. Vasodilation occurs, causing an increase in hydrostatic pressure.