Medical Surgical Critical Care Shock #1

Question

A client from a nursing home is sent to the emergency department for a massive GI bleed. The client has cold and clammy skin, BP 80/40, HR 128, RR 28, and urine output less than 10 ml/hr. Which of these interventions should be implemented immediately? Select all that apply.

Answers

  1. Place the client in High-Fowler's position.
    • Rationale:

      This answer is not correct because raising the client’s HOB will decrease the client’s BP even more and should be avoided.

  2. Start an IV fluid bolus of 0.9% Normal Saline.
    • Rationale:

      This answer is correct because starting an IV fluid bolus of 0.9% Normal Saline will help increase the client’s body fluid volume and increase BP.

  3. Insert a 16 F Foley catheter.
    • Rationale:

      This answer is correct because inserting a 16F Foley catheter should be implemented to monitor accurate urinary output.

  4. Place the client in a flat position.
    • Rationale:

      This answer is correct because placing the client flat will help increase the client’s BP. Raising the client’s HOB will decrease the client’s BP even more and should be avoided.

  5. Start a second IV of Norepinephrine.
    • Rationale:

      This answer is correct because starting a second IV of Norepinephrine will help raise the client’s BP and helps with fluid resuscitation.

Overview

The client with a massive GI bleed and vital signs: BP 80/40, HR 128, RR of 28, plus urine output of less than 10 ml/hr is in hypovolemic shock from the blood loss. The client needs interventions immediately to survive.

Explanation

Learning Outcomes

Interventions to be implemented immediately include: starting an IV fluid bolus of 0.9% Normal Saline to help increase the client’s body fluids and increase BP, inserting a 16F Foley catheter to monitor accurate urinary output, placing the client flat to help increase the BP, and starting a second IV of Norepinephrine to help raise the client’s BP. Raising the client’s HOB will decrease the client’s BP even more and should be avoided.

Test Taking Tip

Know the main symptoms of hypovolemic shock and the priority interventions to implement.

Video Rationale