A 35-year-old patient arrives at the emergency department following a motor vehicle accident. The nurse assesses the patient and notes tachycardia, hypotension, and cool clammy skin. The patient reports feeling lightheaded. Which of the following interventions should the nurse prioritize?
A. Administering pain medication
B. Initiating fluid resuscitation
C. Providing warm blankets
D. Ordering a blood transfusion
E. Scheduling a chest X-ray
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Rationale: In hypovolemic shock, there is a significant loss of intravascular volume leading to inadequate tissue perfusion. Prioritizing fluid resuscitation helps restore circulating blood volume, improve perfusion, and address the underlying cause of the shock. Pain medication, warm blankets, blood transfusion, and chest X-ray may be necessary at later stages, but immediate fluid replacement is crucial for stabilization.
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Understanding Hypovolemic Shock: NCLEX Priority Questions
A 48-year-old female patient with a history of gastrointestinal bleeding presents with weakness, dizziness, and hematemesis. The nurse suspects hypovolemic shock. What assessment finding is most indicative of this condition?
A. Elevated temperature
B. Decreased urine output
C. Increased respiratory rate
D. Hypertension
E. Dilated pupils
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Rationale: In hypovolemic shock, the body compensates by shunting blood away from non-essential organs, including the kidneys, leading to decreased urine output. This reflects the body’s attempt to conserve fluid and maintain blood pressure. Elevated temperature, increased respiratory rate, hypertension, and dilated pupils are not specific to hypovolemic shock and may occur in other conditions.
Understanding Hypovolemic Shock: NCLEX Delegation Questions
A 25-year-old male is brought to the emergency room after sustaining a penetrating abdominal injury. The nurse observes signs of hypovolemic shock. Which laboratory result is consistent with this condition?
A. Increased hemoglobin levels
B. Elevated serum sodium
C. Decreased hematocrit
D. Normal blood glucose
E. Elevated white blood cell count
Rationale: Hypovolemic shock results in a decreased concentration of red blood cells in the blood, leading to a lower hematocrit. This is due to the loss of blood volume without a proportional increase in red blood cell production. Increased hemoglobin levels, elevated serum sodium, normal blood glucose, and an elevated white blood cell count are not specific indicators of hypovolemic shock and may be seen in other conditions.
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Understanding Hypovolemic Shock: Causes and Symptoms
A 28-year-old patient with a known allergy to peanuts accidentally consumes a food item containing peanuts. The nurse assesses the patient and notes the sudden onset of dyspnea, wheezing, and generalized hives. What is the priority nursing intervention?
A. Administering an antipyretic
B. Initiating fluid resuscitation
C. Administering an epinephrine injection
D. Providing oxygen therapy
E. Ordering a chest X-ray
Rationale: Anaphylactic shock is a severe allergic reaction that can rapidly progress to a life-threatening situation. Administering an epinephrine injection is the priority intervention to counteract the systemic effects of the allergen, including bronchoconstriction, vasodilation, and increased vascular permeability. Antipyretics, fluid resuscitation, oxygen therapy, and chest X-ray may be necessary in other situations but are not the immediate priority in managing anaphylactic shock.
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NCLEX Practice Questions: Understanding Hypovolemic Shock Causes and Symptoms
A 35-year-old patient develops anaphylactic shock after receiving a medication. The nurse assesses the patient and notes hypotension, stridor, and confusion. Which medication should the nurse anticipate administering first?
A. Antibiotics
B. Antihypertensive
C. Antihistamine
D. Corticosteroid
E. Epinephrine
Rationale: Epinephrine is the first-line medication for the treatment of anaphylactic shock. It acts rapidly to counteract bronchoconstriction, improve blood pressure, and reduce systemic allergic responses. Antibiotics, antihypertensives, antihistamines, and corticosteroids may be used as adjunctive therapies, but epinephrine is essential for immediate reversal of the life-threatening effects of anaphylactic shock.
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NCLEX Questions: Focus on Medications Hypovolemic Shock
A 40-year-old patient develops anaphylactic shock after a bee sting. The nurse assesses the patient and notes facial swelling, hypotension, and tachycardia. What additional assessment finding is consistent with anaphylactic shock?
A. Elevated temperature
B. Bradypnea
C. Hyperglycemia
D. Increased urine output
E. Cyanosis
Rationale: Cyanosis is a potential manifestation of anaphylactic shock, indicating severe hypoxia due to airway obstruction or respiratory distress. Elevated temperature, bradypnea, hyperglycemia, and increased urine output are not specific to anaphylactic shock and may be seen in other conditions.
NCLEX Focus Exploring Hypovolemic Shock: Causes and Diagnosis
A 25-year-old patient with a history of allergies experiences anaphylactic shock after ingesting a shellfish dish. The nurse assesses the patient and notes difficulty breathing, a rapid weak pulse, and chest pain. What should the nurse prioritize in the initial management of this patient?
A. Administering an antipyretic
B. Administering a vasopressor
C. Administering an anticoagulant
D. Initiating fluid resuscitation
E. Administering epinephrine
Rationale: In the management of anaphylactic shock, the priority is to administer epinephrine to address bronchoconstriction, improve blood pressure, and counteract systemic allergic responses. Antipyretics, vasopressors, anticoagulants, and fluid resuscitation may be needed later but do not address the immediate life-threatening effects of anaphylactic shock.
NCLEX Review: Hypovolemic Shock Treatments
A 30-year-old patient experiences anaphylactic shock following a dose of intravenous contrast dye during a diagnostic procedure. The nurse assesses the patient and notes hypotension, angioedema, and respiratory distress. What is the nurse’s priority action?
A. Administering an antiemetic
B. Administering an anticoagulant
C. Administering an antipyretic
D. Initiating fluid resuscitation
E. Administering epinephrine
Rationale: Epinephrine is the primary intervention for anaphylactic shock, as it acts quickly to reverse bronchoconstriction, improve blood pressure, and mitigate systemic allergic responses. Antiemetics, anticoagulants, antipyretics, and fluid resuscitation may be required for supportive care, but addressing the immediate life-threatening effects with epinephrine is crucial in managing anaphylactic shock.
NCLEX Questions Critical Thinking: Hypovolemic Shock Symptoms
A 22-year-old patient presents to the emergency department with sudden-onset difficulty breathing, swelling of the face and tongue, and hypotension after consuming a seafood dish. The nurse suspects anaphylactic shock. What is the most immediate nursing action?
A. Administering an antipyretic
B. Initiating fluid resuscitation
C. Administering an antihistamine
D. Administering an epinephrine injection
E. Ordering a chest X-ray
Rationale: Anaphylactic shock is a life-threatening allergic reaction that requires immediate intervention. Administering an epinephrine injection is the priority to counteract bronchoconstriction, vasodilation, and systemic allergic responses. Antipyretics, fluid resuscitation, antihistamines, and chest X-rays may be necessary in other situations but are not the immediate priority in managing anaphylactic shock.
A 30-year-old patient experiences anaphylactic shock after being stung by a bee. The nurse assesses the patient and notes wheezing, chest tightness, and facial swelling. What is the primary nursing intervention for this patient?
A. Administering an antibiotic
B. Initiating fluid resuscitation
C. Administering an antipyretic
D. Administering an epinephrine injection
E. Ordering a complete blood count
Rationale: The immediate priority in managing anaphylactic shock is to administer epinephrine to counteract bronchoconstriction, improve blood pressure, and reduce systemic allergic responses. Antibiotics, fluid resuscitation, antipyretics, and complete blood counts may be necessary in other situations but are not the first-line intervention for anaphylactic shock. Administering epinephrine is crucial in preventing the progression of this life-threatening reaction.