Nursing Interventions in Shock Management

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What is the primary goal when managing a shock state?

Restoring normal blood pressure

Administering oxygen

Optimizing tissue perfusion (correct)

Documenting the event

What is the first action the nurse should take when a client develops an anaphylactic reaction?

Quickly assess the client's respiratory status (correct)

Start an IV infusion of D5W and administer a 500-mL bolus

Leave the client to contact a PHCP

Document the event

What is essential for the nurse to do when a client develops an anaphylactic reaction?

Stay with the client until the reaction is resolved (correct)

Leave the client briefly to contact a PHCP

Keep the client supine regardless of blood pressure readings

Administer oxygen

What is a key intervention for managing shock?

Fluid volume restoration Signup and view all the answers

Why is it essential to prioritize perfusion in a shock state?

To ensure adequate tissue perfusion Signup and view all the answers

What is a consequence of ineffective perfusion in a shock state?

Decreased CVP and MAP Signup and view all the answers

What is the primary concern for the client with anemia and an elevated temperature?

Assessing the client's vital signs and overall condition Signup and view all the answers

Why should the nurse notify the PHCP before taking any action?

To follow the PHCP's instructions regarding blood transfusion and medication administration Signup and view all the answers

What should the nurse do first when a client with anemia has an elevated temperature?

Notify the PHCP about the elevated temperature Signup and view all the answers

What is the primary focus when dealing with a client who has anemia and an elevated temperature?

Following the PHCP's instructions and prioritizing the client's condition Signup and view all the answers

What should the nurse prioritize when a client's temperature is above the normal range before a scheduled blood transfusion?

Notifying the PHCP about the elevated temperature Signup and view all the answers

What is the importance of the mnemonic 'Notify PHCP first'?

To prioritize notifying the PHCP before taking any action Signup and view all the answers

What is the primary purpose of continuous renal replacement therapy (CRRT)?

To remove urinary toxins and excess fluid from clients with acute kidney injury Signup and view all the answers

What is required to be maintained above 60 mm Hg for CRRT to be successful?

Mean arterial pressure Signup and view all the answers

What is the importance of maintaining a MAP above 60 mm Hg during CRRT?

To allow for effective clearance of urinary toxins Signup and view all the answers

What is removed as the client's blood passes through a hemofilter during CRRT?

Water, electrolytes, and other solutes Signup and view all the answers

Why is CRRT often used in clients with acute kidney injury or chronic kidney disease?

Because they cannot tolerate hemodialysis Signup and view all the answers

What is the duration of treatment using CRRT?

Between 8 to 24 hours Signup and view all the answers

What is the most critical aspect of addressing circulatory overload?

Prioritizing interventions based on urgency Signup and view all the answers

What is an indication that a client receiving tricyclic antidepressants is following the medication plan correctly?

Client arrives at the clinic neat and appropriate in appearance Signup and view all the answers

What is a common symptom of depression that is resolved with therapeutic effect from medication?

Sleeping for long periods Signup and view all the answers

What is the primary goal of prioritizing interventions based on urgency?

To provide immediate care to the client Signup and view all the answers

What is a common challenge that nurses may face when addressing circulatory overload?

Recognizing signs and symptoms of circulatory overload Signup and view all the answers

What is the relationship between prioritization and addressing circulatory overload?

Prioritization is a prerequisite for addressing circulatory overload Signup and view all the answers

What should the nurse prioritize when assessing a client with depression symptoms?

Focusing on identifying depression symptoms Signup and view all the answers

What is essential for the nurse to do when a client is prescribed bupropion?

Monitor for signs of seizure activity Signup and view all the answers

What is a key aspect of managing depression symptoms?

Assessing the client's symptoms and medication adherence Signup and view all the answers

What is a nursing intervention for assessing and supporting medication adherence?

Providing education on the importance of medication compliance Signup and view all the answers

What is an important aspect of depression assessment and management?

Identifying depression symptoms and improvement in appearance Signup and view all the answers

What is a key sign of therapeutic response in a client with depression?

Appearance improvement Signup and view all the answers