A 45-year-old patient presents to the trauma unit after a gunshot wound (GSW) to the abdomen. The patient has a temperature of 92 degrees Fahrenheit, is restless and confused, and has large amount of blood noted from the nasogastric (NG) tube as well as from the indwelling urinary catheter. Which additional assessment finding likely causes death within the first 24 hours following this injury?

Heart rate of 130 beats per minute

PH of 7.21 (normal 7.35-7.45)

Serum potassium 5.7 mEq/L (normal 3,5-5.3)

Platelet count 200,000 (normal 150,000-450,000)

Answer and Explanation

The Correct Answer is B

A) Heart rate of 130 beats per minute
A heart rate of 130 beats per minute is tachycardia, which is often a compensatory response to injury, particularly in cases of trauma, blood loss, or shock. It is common in the initial phase after trauma as the body attempts to compensate for decreased blood volume or oxygen delivery. However, tachycardia alone is not typically fatal in the immediate post-injury period and can often be managed.

B) pH of 7.21 (normal 7.35–7.45)
A pH of 7.21 indicates acidosis, which is life-threatening and typically arises from shock, blood loss, or severe trauma. Acidosis occurs when the body is unable to compensate for lactic acid or other metabolic byproducts that accumulate due to insufficient oxygen delivery to tissues. In the case of a gunshot wound to the abdomen, there is a high risk of internal bleeding, hypoperfusion, and hypoxia, all of which can lead to metabolic acidosis. Severe acidosis can cause organ failure, particularly affecting the heart, kidneys, and brain.

C) Serum potassium 5.7 mEq/L (normal 3.5–5.3)
A serum potassium of 5.7 mEq/L is elevated, but it is moderately high and not typically life-threatening unless it reaches much higher levels (e.g., >6.0 mEq/L), which can cause cardiac arrhythmias. Elevated potassium can occur due to cellular injury (e.g., muscle trauma or rhabdomyolysis), but it would need to be corrected to prevent complications like arrhythmias.

D) Platelet count 200,000 (normal 150,000–450,000)
A platelet count of 200,000 is within the normal range (150,000–450,000) and does not indicate a problem with coagulation. The blood loss and the NG tube hemorrhage mentioned in the scenario suggest that the patient may be at risk for bleeding, but a platelet count in the normal range suggests that the body’s ability to form clots is likely intact.

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Correct Answer is ["A","B","E"]

Explanation

A) Assess the respiratory status hourly and as needed
It is essential for the nurse to frequently monitor and assess the respiratory status of a client on a ventilator, as changes can occur rapidly. Regular assessments allow the nurse to detect any early signs of respiratory distress, hypoxia, or ventilator malfunction. Hourly assessments are standard practice in the intensive care unit (ICU), and additional assessments may be necessary if there are concerns about the patient’s respiratory condition.

B) Ensure that a manual resuscitation bag is at the bedside
A manual resuscitation bag (Ambu bag) is a critical piece of emergency equipment that should always be available at the bedside of a patient on mechanical ventilation. In the event of ventilator failure, accidental extubation, or sudden respiratory distress, the nurse needs to be able to provide manual ventilation.
C) Check the patient's pulse oximetry once every shift
Although monitoring pulse oximetry is important in ICU patients on a ventilator, checking it only once per shift is insufficient. Continuous monitoring of oxygen saturation via pulse oximetry is a much more appropriate approach to ensure the patient is adequately oxygenated, especially when on a ventilator.

D) Adjust the ventilator settings based on the client’s level of consciousness
Adjusting the ventilator settings should be done by the healthcare provider or respiratory therapist, not the nurse, unless directed by the provider. While the patient's level of consciousness can influence their respiratory drive, the nurse does not have the authority or expertise to modify ventilator settings based on consciousness levels.

E) Collaborate frequently with the respiratory therapist
Collaboration with the respiratory therapist is essential for managing a patient on a ventilator. Respiratory therapists have specialized training in ventilator management and can assist with adjusting ventilator settings, monitoring the patient’s lung function, and troubleshooting ventilator malfunctions.

A. Packed Red Blood Cells (PRBC's) B. Platelets C. Cryoprecipitate D. Fresh Frozen Plasma (FFP)

Correct Answer is D

Explanation

A) Packed Red Blood Cells (PRBCs):
Packed Red Blood Cells are typically transfused when there is anemia or significant blood loss leading to low hemoglobin levels. In the case of warfarin overdose or elevated PT/INR, the problem is related to coagulation and not red blood cell count.

B) Platelets:
Platelets are typically transfused when there is thrombocytopenia or a need to address platelet dysfunction (e.g., in patients with bleeding due to low platelet counts). However, the elevated PT and INR in this case are related to the coagulation cascade being inhibited by warfarin, not platelet deficiency.

C) Cryoprecipitate:
Cryoprecipitate is primarily used to replace clotting factors such as fibrinogen, factor VIII, and von Willebrand factor. It is typically transfused in patients with hemophilia or bleeding disorders related to low fibrinogen levels. However, in this case, the issue is related to warfarin-induced inhibition of clotting factors (specifically the vitamin K-dependent factors: II, VII, IX, and X), not a deficiency in fibrinogen or specific clotting factors addressed by cryoprecipitate.

D) Fresh Frozen Plasma (FFP):
Fresh Frozen Plasma (FFP) is the most appropriate choice for this patient. FFP contains all the coagulation factors, including the vitamin K-dependent factors that warfarin inhibits. When a patient on warfarin presents with elevated PT and INR (which indicates impaired clotting ability), FFP is used to replace the clotting factors and help reverse the effects of warfarin.

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Naxlex Comprehensive Predictor Exams

The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Correct Answer is ["A","B","E"]

Explanation

The nurse is caring for patient with a history of atrial fibrillation who is prescribed warfarin. Sometimes I forget my medication, so l double up doses when I remember " The patient's PT and INR are highly elevated. The nurse anticipates the transfusion of which blood product?

Correct Answer is D

Explanation

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