The nurse suspects shock in a child 1 day after surgery. What should be the initial nursing action?
a. Place the child on a cardiac monitor.
b. Obtain arterial blood gases.
c. Provide supplemental oxygen.
d. Put the child in the Trendelenburg position.
ANS: C
The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need for intubation. Cardiac monitoring would be indicated to assess the child's status further, but ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available. The Trendelenburg position is not indicated and is detrimental to the child. The head-down position increases intracranial pressure and decreases diaphragmatic excursion and lung volume.
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