A nurse is caring for a 30-year-old postoperative patient who underwent emergency appendectomy 8 hours ago and suddenly develops hypotension (BP 75/45 mmHg), tachycardia (HR 140 bpm), decreased urine output (10 mL/hr), and pale, diaphoretic skin. Which nursing action should be the FIRST priority?
1Administer prescribed pain medication to reduce patient anxiety
2Increase the IV fluid infusion rate to 150 mL/hr
3Apply oxygen via nasal cannula at 2 L/min✓ 정답
4Place the patient in Trendelenburg position
해설
In shock, immediate priority is to support oxygenation via oxygen administration to prevent hypoxemia. Other options like Trendelenburg position or pain medication are secondary or not evidence-based.
Clinical Judgment
This question assesses your ability to recognize the signs of Hypovolemic Shock in a postoperative patient and determine the immediate priority action: Notify HCP! The core is the initial response to an immediate life threat. The patient's signs (hypotension, tachycardia, anuria, cool and clammy skin) clearly indicate advanced shock. In this situation, the nurse's first action is to take immediate measures to stabilize the patient while simultaneously calling the healthcare provider to initiate comprehensive treatment. Option 4 does both: the Trendelenburg position temporarily increases venous return to the heart to maintain brain and heart perfusion, and notifying the physician is an essential step to rapidly begin definitive care such as fluid resuscitation, medications, or further surgical intervention.
Memory Tip: A mnemonic for remembering priorities in shock: Position & Page. "Change the Position, and Page right away!" Even within the ABC (Airway, Breathing, Circulation) framework, in such obvious circulatory shock, immediate positioning and team activation take precedence.
KR vs US: In Korea, the Trendelenburg position may be used restrictively due to risks like cerebral edema, but in NGN/US nursing standards, it is taught as an important nursing intervention for the initial emergency response to acute hypovolemic shock that can be performed without a physician's order. The key point is that it must be accompanied by Notify HCP! notifying the physician.
Clinical Practice GuideSudden hypotension, tachycardia, and oliguria in a postoperative patient are red flags for life-threatening complications such as hemorrhage or sepsis. Notify HCP! Nurses must respond systematically as soon as these signs are recognized.Caution: A common trap in SATA (Select All That Apply) questions is choosing specific interventions like "administer oxygen" or "increase IV fluid rate" as the first action. While oxygen is important, unless the patient's airway is compromised and they are complaining of respiratory distress, it is not an absolute priority over repositioning to address circulatory shock and notifying the team. Critical Cue Increasing the IV fluid rate requires a physician's order, and doing so blindly without knowing the cause (e.g., hemorrhage) can be dangerous.
Hypovolemic Shock — Hypovolemic shock. A life-threatening condition where circulating blood volume decreases rapidly, preventing adequate oxygen and nutrient delivery to tissues. Causes include postoperative bleeding, dehydration, and burns.
Trendelenburg Position — Trendelenburg position. A position where the patient's head is lowered and legs are elevated. Used to temporarily increase venous return to the heart in acute hypovolemic shock.
Oliguria — Anuria. In adults, a state where urine output is less than 30 mL per hour. It is an important indicator of decreased renal perfusion and a sign of shock.
Hypotension — Hypotension. Generally, a state where systolic blood pressure is less than 90 mmHg. Can cause inadequate tissue perfusion.
Tachycardia — Tachycardia. Generally, in adults, a resting heart rate of 100 beats per minute or more. A compensatory mechanism to maintain cardiac output during shock.