A client who has sustained blunt abdominal trauma is admitted to the ICU. Upon assessment the nurse notices the following vital signs: T-99F; HR- 148: RR-38; B/P-60/40. The client is diaphoretic and restless. The following selections are approved by the ICU physician. What would be the PRIORITY nurse's action?

Auscultate bowel sounds, record the findings and obtain a 12-lead ECG

Initiate the standing prescription for v Dopamine at 16 mcg/kg/minute

Place soft restraints on the upper extremities and sedate as necessary

Lower the head the bed obtain a pulse ox and increase the rate of iv fluids

Answer and Explanation

The Correct Answer is D

A. Auscultate bowel sounds, record the findings, and obtain a 12-lead ECG
While auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.

B. Initiate the standing prescription for Dopamine at 16 mcg/kg/minute
Dopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.

C. Place soft restraints on the upper extremities and sedate as necessary
The client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.

D. Lower the head of the bed, obtain a pulse ox, and increase the rate of IV fluids
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.

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

Explanation

A. Distributive shock

Severe burns lead to systemic inflammatory response syndrome (SIRS), causing massive vasodilation, similar to septic shock (a type of distributive shock).

D. Hypovolemic shock

Fluid loss from burns leads to hypovolemic shock, which is the most common type of shock seen in burn patients.

B. Cardiogenic shock

Cardiogenic shock is caused by heart failure and is not a primary concern in burn injuries.

C. Obstructive shock

Obstructive shock (e.g., tension pneumothorax, cardiac tamponade) does not occur in burn patients unless another condition is present.

E. Neurogenic shock

Neurogenic shock occurs from spinal cord injuries, not burns.

A. Assessment of neurologic status B. Obtain IV access with two large bore lines and blood for lab studies C. Placement of a naso-gastric tube to decompress the stomach D. Placement of an indwelling catheter (Foley) to measure urine output

Correct Answer is B

Explanation

A. Assessment of neurologic status
While neurological assessment is important, it is not the priority in this situation. The immediate priority is managing the chest wound and airway to ensure oxygenation and prevent further complications.

B. Obtain IV access with two large bore lines and blood for lab studies
IV access is important for fluid resuscitation and medication administration but is not the immediate priority compared to securing the airway and ensuring ventilation.

C. Placement of a naso-gastric tube to decompress the stomach
Although the naso-gastric tube may be necessary to decompress the stomach later, it is not the priority in the initial management of a client with a gunshot wound to the chest.

D. Placement of an indwelling catheter (Foley) to measure urine output
While measuring urine output is important for monitoring renal function and fluid balance, it is not the priority in this emergency situation.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)

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

Explanation

The nurse is caring for a client who has suffered a gunshot wound to the anterior chest. The client has been intubated and is currently being ventilated with a bag-valve device. What is the priority intervention for this client now?

Correct Answer is B

Explanation

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