A nurse is caring for a postoperative patient who suddenly develops signs of hypovolemic shock. Which nursing intervention should be the nurse's FIRST priority?

A 60-year-old patient underwent hip replacement surgery 4 hours ago and is now showing signs of hypovolemic shock with blood pressure 80/50 mmHg, heart rate 120 bpm, weak pulse, cool clammy skin, and decreased urine output.

1 Establish large-bore IV access and initiate fluid resuscitation ✓ 정답
2 Administer prescribed pain medication to reduce patient discomfort
3 Place the patient in Trendelenburg position to improve venous return
4 Obtain blood samples for laboratory analysis including CBC and electrolytes

해설

In hypovolemic shock, the priority is to restore circulating blood volume through fluid resuscitation via large-bore IV access to prevent cardiovascular collapse and organ failure.

심화 해설

Core Nursing Explanation Key Concept Analysis: This question assesses the priority nursing intervention for a patient in hypovolemic shock. The core pathophysiology is an absolute loss of intravascular volume (e.g., from hemorrhage post-surgery), leading to decreased cardiac output, poor tissue perfusion, and cellular hypoxia. The nursing priority is to reverse this process immediately to prevent irreversible organ damage and death.

Answer Rationale: Key Point! The FIRST priority in hypovolemic shock is to restore circulating volume. Establishing large-bore IV access (e.g., two 18-gauge or larger catheters) is the critical first step to enable rapid fluid resuscitation with crystalloids (e.g., Normal Saline or Lactated Ringer's). This directly addresses the root cause—hypovolemia—and supports blood pressure and organ perfusion. This action aligns with the ABC (Airway, Breathing, Circulation) priority framework, where "Circulation" is paramount in this scenario.

Distractor Analysis: Watch out for confusion! Option ② (Administer pain medication) is incorrect because analgesics, especially opioids, can cause vasodilation and further drop blood pressure, worsening the shock state. Pain management is important but is a secondary concern to life-threatening hypovolemia.
Option ③ (Place in Trendelenburg position) is an outdated and potentially harmful intervention. While it was once thought to improve venous return, it can actually impair pulmonary function and does not significantly improve cardiac output. The current standard is to keep the patient supine with legs elevated (Modified Trendelenburg) if necessary, but establishing IV access is still the definitive first action.
Option ④ (Obtain blood samples) is an important diagnostic step but is not the immediate priority. Lab results take time, and treatment must begin empirically based on clinical signs. Volume resuscitation should not be delayed for lab draws.

Related Concepts: This scenario integrates knowledge of shock management, postoperative complications, and nursing prioritization (ABCs). Remember, in any shock state, identifying and treating the underlying cause (hemorrhage -> volume replacement) is paramount.
Concept Summary

Concept	Key Takeaway
Hypovolemic Shock Pathophysiology	Loss of intravascular volume -> decreased preload -> decreased stroke volume & cardiac output -> hypotension & tissue hypoxia.
Nursing Priority (ABCs)	Circulation is the immediate concern. Secure IV access to administer fluids/blood.
Primary Intervention	Rapid volume replacement via large-bore IV catheters.
Monitoring Parameters	Vital signs (BP, HR), urine output ( 임상 시나리오 Nursing Clinical Practice Guide Clinical Scenario: You are the nurse on a surgical floor. Mr. Jones, 4 hours post right total hip replacement, is restless. His BP has dropped from 130/80 to 80/50, HR is 120 and thready, skin is pale and clammy, and his Foley catheter bag shows only 15 mL of dark urine in the last hour. The surgical dressing is intact but has a moderate amount of sanguineous drainage. Nursing Intervention Strategy: 1. Immediate Action & Assessment: Call for help (activate rapid response/code team per protocol) while simultaneously moving to establish two large-bore (16- or 18-gauge) IV lines. Assess the surgical site and under the patient for hidden bleeding. Apply oxygen via non-rebreather mask at 10-15 L/min. 2. Implementation: Once IV access is secured, immediately initiate a rapid infusion of Normal Saline or Lactated Ringer's as ordered (e.g., 1-2 liter bolus). Anticipate orders for blood transfusion (type and crossmatch) and possibly return to the OR for bleeding control. 3. Ongoing Monitoring & Evaluation: Continuously monitor vital signs, oxygen saturation, and level of consciousness. Strict I&O (Intake and Output). Reassess after each fluid bolus. The goal is to restore urine output to >0.5 mL/kg/hr and improve hemodynamics. Patient Safety and Precautions: Use warmed IV fluids if possible to prevent hypothermia. When giving rapid fluid boluses, auscultate lung sounds frequently to assess for signs of fluid overload (crackles). Monitor for transfusion reactions if blood products are given. Nursing Procedure & Medication Flow Procedure: Establishing Large-Bore IV Access for Resuscitation Gather equipment: Two IV start kits, 16- or 18-gauge catheters, IV tubing, 1L bags of isotonic crystalloid. Select large, proximal veins (e.g., antecubital). Insert catheter, secure firmly, and label with date/time/gauge. Prime tubing, connect to fluid, and open roller clamp fully for rapid infusion. Use pressure bags if available to increase flow rate. Document sites, gauge, and time of initiation. Medication: Isotonic Crystalloid Fluids Normal Saline (0.9% NaCl): First-line for resuscitation. Caution in patients with heart failure or renal impairment. Lactated Ringer's (LR): Often preferred as it more closely matches plasma electrolyte composition. Avoid in liver failure (impaired lactate metabolism). A Word from Your Senior Nurse "In the chaos of a crashing patient, your training kicks in. Remember your ABCs. For this post-op patient, the 'C' (Circulation) is screaming for help. Your hands starting that IV are the direct lifeline. In clinicals and on the NCLEX, they're testing your ability to cut through the noise and do the one thing that will save a life right now. It's not about the lab work or the perfect bed position—it's about volume, volume, volume. Master this thought process, and you'll handle not just test questions, but real bedside emergencies with clarity and confidence." 핵심 개념 Hypovolemic Shock — A life-threatening condition where severe loss of blood or fluid decreases intravascular volume, leading to inadequate tissue perfusion and organ dysfunction. Fluid Resuscitation — The rapid administration of intravenous fluids (crystalloids or colloids) to restore circulating volume and correct hypovolemia in shock states. Preload — The degree of stretch of the cardiac muscle fibers at the end of diastole, directly related to the volume of blood returning to the heart (venous return). Reduced in hypovolemia. Trendelenburg Position — A position where the patient's head is lowered and feet are elevated. Historically used for shock but is now contraindicated as it can impair respiratory function and is not proven to improve outcomes. ABC Priority — A fundamental framework for assessment and intervention: Airway, Breathing, Circulation. Guides nurses to address the most immediate life-threatening issues first. 마이메르시로 국가고시 완벽 대비 기출문제와 상세 해설을 무료로. 내 약점을 분석하고 진도를 관리하며 더 똑똑하게 공부하세요. 무료로 시작하기 App Store Google Play 학습 참고용입니다. 실제 임상은 최신 지침과 소속 기관 프로토콜을 따르세요. 같은 주제 문제 A nurse is caring for a postoperative patient who suddenly becomes restless, with decrease… A nurse is caring for a postoperative patient who suddenly develops severe dyspnea, chest … A nurse is caring for a postoperative patient who suddenly develops signs of shock. Which … A nurse is caring for a postoperative patient who suddenly develops signs of pulmonary emb… A nurse is caring for a postoperative patient who suddenly develops signs of shock. Which … A nurse is caring for a 45-year-old postoperative patient who underwent major abdominal su… A nurse is assessing a patient who underwent exploratory laparotomy for bowel obstruction … A nurse is caring for a postoperative patient who underwent major abdominal surgery 48 hou…

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A nurse is caring for a postoperative patient who suddenly develops signs of hypovolemic shock. Which nursing intervention should be the nurse's FIRST priority?

심화 해설

임상 시나리오

핵심 개념

마이메르시로 국가고시 완벽 대비