A nurse is caring for a postoperative patient who suddenly develops signs of shock. Which nursing action should be the FIRST priority?
A 45-year-old patient underwent major abdominal surgery 6 hours ago and suddenly develops hypotension (BP 85/50 mmHg), tachycardia (HR 125 bpm), decreased urine output (15 mL/hr), and cool, clammy skin.
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
4Place the patient in Trendelenburg position✓ 정답
해설
In shock, immediate priority is improving venous return and cerebral perfusion via Trendelenburg position while alerting the team. Other options address secondary needs or require orders.
Core Nursing ExplanationKey Concept Analysis: This question assesses the priority nursing action for a patient in hypovolemic shock. The patient is postoperative, a high-risk period for complications like hemorrhage. The signs—hypotension (BP 85/50 mmHg), tachycardia (HR 125 bpm), oliguria (15 mL/hr), and cool, clammy skin—are classic indicators of compensated hypovolemic shock. The body is trying to maintain perfusion to vital organs (heart, brain) by shunting blood away from the periphery and kidneys.
Answer Rationale: Key Point! The FIRST priority in managing shock is to improve perfusion to the brain and heart. The Trendelenburg position (head down, feet elevated) uses gravity to promote venous return from the lower extremities to the central circulation, which can temporarily improve preload, cardiac output, and cerebral perfusion. This is an immediate, independent nursing action that can be taken while calling for help and preparing for further interventions like fluid resuscitation.
Distractor Analysis:
Watch out for confusion! Option ① (Administer pain medication) is incorrect because sedatives or opioids can further depress the respiratory and cardiovascular systems, worsening hypotension. Anxiety in this context is a physiological response to shock, not a primary problem.
Option ② (Increase IV rate) is a critical intervention for hypovolemia but is not the first action. Rapid fluid administration requires a physician's order, and the nurse must first ensure the patient is positioned to optimize the effect of the fluids. The initial action is to position, then call for orders/help, then administer fluids.
Option ③ (Apply oxygen) is very important because shock leads to tissue hypoxia. However, improving oxygen delivery is futile if there isn't enough blood volume to carry the oxygen. Positioning to improve circulation is a more immediate foundational step. Oxygen would be applied immediately after or concurrently with positioning.
Related Concepts: This scenario integrates the ABC (Airway, Breathing, Circulation) priority framework. While Airway and Breathing are always first, this patient is breathing. The immediate circulatory problem is addressed by positioning to enhance circulation. This also demonstrates the principle of independent vs. dependent nursing actions. Trendelenburg is independent; administering IV fluids or medications requires an order.
Concept Summary
Concept
Key Takeaway
Hypovolemic Shock
Inadequate circulating volume leads to poor tissue perfusion. Post-op patients are at high risk for hemorrhage.
Nursing Priority (Shock)
1. Position (Trendelenburg) 2. Call for Help 3. Administer O2 4. Establish IV access/fluids 5. Monitor vitals & source of loss.
Compensatory Mechanisms
Tachycardia, vasoconstriction (cool skin), decreased urine output are the body's attempts to maintain BP.
Side-by-Side Comparison!
Shock Position
Purpose & Indication
Contraindications/Cautions
Trendelenburg (Head down, feet up 15-30 degrees)
Improves venous return & cerebral perfusion in hypovolemic shock.
Avoid in head injury, increased ICP, respiratory distress. Not for cardiogenic shock.
Same goal, less risk of abdominal pressure on diaphragm and increased ICP.
Often preferred over full Trendelenburg in modern practice.
Supine with Legs Elevated
Simple first aid for suspected shock or syncope.
Appropriate initial action.
Anatomy, Physiology & Pharmacology Points
The autonomic nervous system compensates for low blood volume by releasing catecholamines (epinephrine, norepinephrine). This causes vasoconstriction (cool skin) and increased heart rate (tachycardia) to maintain cardiac output. The renin-angiotensin-aldosterone system (RAAS) is activated, leading to sodium and water retention, which is why urine output drops dramatically.
Memory TipsShock First Response - "P.L.A.C.E. the Patient": Position (Trendelenburg/legs up) Let someone know (Call for help/rapid response) Airway & O2 (Apply oxygen) Circulation access (2 large-bore IVs) Evaluate cause & monitor
High-Frequency NCLEX Topics
Prioritization ("first," "initial," "priority") and delegation in emergency situations are classic NCLEX themes. Know the order of actions for common emergencies like shock, anaphylaxis, and cardiac arrest. The exam will test your ability to distinguish between an urgent, independent action and an important but order-dependent intervention.
Watch Out for Question Variations!
* Instead of asking for the first action, it might ask: "The nurse places the patient in Trendelenburg position. Which finding indicates the intervention is effective?" (Answer: Improved blood pressure or mentation).
* The scenario could change to cardiogenic shock (e.g., post-MI). In that case, the priority is NOT Trendelenburg (it increases cardiac workload), but rather administering oxygen, morphine for pain/preload reduction, and dobutamine as ordered.
* It could be a delegation question: "Which task can the RN delegate to the LPN/LVN?" Assessing the shock patient cannot be delegated; but tasks like obtaining equipment or documenting can be.
Nursing Clinical Practice GuideClinical Scenario: You are doing rounds on your post-op patient, Mr. Johnson. He was alert earlier but now seems restless and says he feels "dizzy." You check his vitals: BP 85/50, HR 128, RR 24, SpO2 94% on room air. His skin is pale and cool to the touch. His abdominal dressing is intact but has a small amount of serosanguinous drainage.
Nursing Intervention Strategy:
1Immediate Action (Independent)Say "Mr. Johnson, I need to help you lie back and elevate your legs to help your circulation." Gently place him in a modified Trendelenburg position (legs elevated, head flat). Activate the call light or yell for help to another staff member.
2Assessment & CommunicationWhile positioning, quickly assess his airway and breathing. As help arrives, instruct a colleague to: "Call the rapid response team (or attending surgeon), bring the crash cart and non-rebreather mask." You apply oxygen at 15 L/min via non-rebreather mask.
3Investigation & PreparationCheck surgical sites more thoroughly. Is there increasing abdominal distention? Check under the patient for pooled blood. Have another nurse establish a second large-bore (16- or 18-gauge) IV line. Anticipate orders for STAT labs (CBC, type and crossmatch) and a fluid bolus (e.g., 1-2 L of Normal Saline or Lactated Ringer's).
Patient Safety and Precautions:
* Key Point! Monitor the patient closely in Trendelenburg position. It can impair respiratory excursion and increase intracranial pressure. If the patient has a head injury or severe respiratory distress, use supine with legs elevated instead.
* When increasing IV fluids, use an infusion pump if possible and monitor for signs of fluid overload (crackles in lungs, worsening shortness of breath), especially if the shock is transitioning from hypovolemic to cardiogenic.
* Never leave a patient in shock alone. Continuously reassess mental status, vital signs, and urine output.
Nursing Procedure & Medication FlowManaging a Patient in Shock:
2Position & CallPosition to improve circulation. Call for help (Rapid Response Team).
3OxygenateApply high-flow oxygen.
4AccessObtain IV access with two large-bore catheters.
5Fluid ResuscitateAdminister isotonic crystalloid bolus per protocol (e.g., 1 L over 15-30 minutes).
6Investigate & TreatIdentify and treat the cause (e.g., prepare for return to OR for hemorrhage control).
7MonitorContinuous vital signs, pulse oximetry, ECG, and urinary catheter for strict I&O.
A Word from Your Senior Nurse
"In the controlled chaos of a patient crashing, your training kicks in. Remember your ABCs, but also remember that sometimes 'C' (circulation) needs a simple, powerful boost first—gravity! Positioning is a tool you always have with you. On the NCLEX and in real life, they're testing your clinical judgment: Can you see the big picture (shock) and act immediately with what you have, while mobilizing the resources for definitive treatment? That's the mark of a safe, competent nurse."