The nurse is caring for the client following a laryngectomy when
suddenly the client becomes unresponsive and pale, with a BP of
90/40. The initial nurse’s action should be to:
❍ A. Place the client in Trendelenburg position.
❍ B. Increase the infusion of normal saline.
❍ C. Administer atropine intravenously.
❍ D. Move the emergency cart to the bedside.
Tough question. In an emergency (even an emergency question), it can be tempting to rush and skip thinking it through because it's an emergency question. It's important to remember that this is a theoretical patient and that we can take all the time we need! First, let's analyze what this question is asking.
Question interpretation: What is the most important thing the nurse can do for a client who is going into shock?
How did we know it's shock? They stated that the patient has just had a procedure done that puts him or her at risk for blood loss (the laryngectomy) and the blood pressure suddenly plummeted. It might not be hemorrhagic shock. It might be. Either way, we need to act like it is and save this patient.
Answer A is correct because it will keep the patient safe (can't fall if he's lying down!) and will increase blood pressure to the head. Once that is accomplished, it would be appropriate to alert the physician in order to get an increase in normal saline (B) to boost the blood pressure or atropine (C) if the physician also thinks the patient is going into shock. Remember, you need orders for rate increases or unanticipated medications like atropine. Also, it's not quite time to move the emergency cart to the bedside (D) yet.
Answer: A
❍ A. Place the client in Trendelenburg position.
❍ B. Increase the infusion of normal saline.
❍ C. Administer atropine intravenously.
❍ D. Move the emergency cart to the bedside.
Tough question. In an emergency (even an emergency question), it can be tempting to rush and skip thinking it through because it's an emergency question. It's important to remember that this is a theoretical patient and that we can take all the time we need! First, let's analyze what this question is asking.
Question interpretation: What is the most important thing the nurse can do for a client who is going into shock?
How did we know it's shock? They stated that the patient has just had a procedure done that puts him or her at risk for blood loss (the laryngectomy) and the blood pressure suddenly plummeted. It might not be hemorrhagic shock. It might be. Either way, we need to act like it is and save this patient.
Answer A is correct because it will keep the patient safe (can't fall if he's lying down!) and will increase blood pressure to the head. Once that is accomplished, it would be appropriate to alert the physician in order to get an increase in normal saline (B) to boost the blood pressure or atropine (C) if the physician also thinks the patient is going into shock. Remember, you need orders for rate increases or unanticipated medications like atropine. Also, it's not quite time to move the emergency cart to the bedside (D) yet.
Answer: A
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