The nurse in the ICU is assessing a client who sustained blunt abdominal trauma. The client has received 3 liters of crystalloid solution in the Emergency Department and 5 units of Packed Red Blood Cells (PRBCs) in the Operating Room. What assessment finding would the nurse report to the physician IMMEDIATELY?
Respiratory rate 24 and bloody drainage in the NG tube
Client is oriented to name and place but not the date
Blood pressure 4/48 and urine output of 24 mL/hour
Hypo-active bowel sounds and tachycardia
The Correct Answer is C
A. Respiratory rate 24 and bloody drainage in the NG tube
While an increased respiratory rate and bloody drainage are concerning, they may not indicate an immediate life-threatening situation compared to the other options.
B. Client is oriented to name and place but not the date
This suggests some level of confusion or altered mental status, which is important but not necessarily an immediate threat.
C. Blood pressure 40/48 and urine output of 24 mL/hour
This indicates severe hypotension and inadequate perfusion, which are signs of ongoing shock and possibly continued internal bleeding. Immediate intervention is critical.
D. Hypo-active bowel sounds and tachycardia
Hypo-active bowel sounds and tachycardia are concerning and suggestive of shock, but they are not as immediately life-threatening as severely low blood pressure and low urine output.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Vocalization, strength, and pupillary response and accommodation are not components of GCS. Strength testing is part of a motor exam, and pupillary response is part of a cranial nerve assessment.
B. Eye opening, verbal response, and motor response are the three components of the Glasgow Coma Scale (GCS), which assesses a client’s neurological status and level of consciousness.
C. Pupillary reaction, eye opening, and motor response is incorrect because pupillary reaction is not a component of the GCS.
D. Motor response, sensory response, and level of consciousness is incorrect because sensory response is not a part of the GCS.
Correct Answer is C
Explanation
A. Deep purple erythema
This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.
B. Facial nerve deficits
This indicates nerve injury, which is serious but may not be immediately life-threatening.
C. Dysphonia or dysphagia
Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.
D. Heart rate of 100 and blood pressure of 96/68
These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.
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