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

Answer and Explanation

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.

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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.

A. Gently cleanse the wounds with warm soapy water B. Remove blistered skin and cover with a dry dressing C. Apply saline soaked wet-to-dry dressings D. Cover with a clean dry sheet to prevent hypothermia

Correct Answer is D

Explanation

A. Gently cleanse the wounds with warm soapy water

Initial burn care focuses on preventing hypothermia and infection. Cleaning is usually performed in a controlled setting like a burn unit, not in the emergency phase.

B. Remove blistered skin and cover with a dry dressing

Blisters should not be removed in the initial phase unless they are large and tense. Removal increases the risk of infection.

C. Apply saline-soaked wet-to-dry dressings

Wet dressings can lead to hypothermia in burn patients, which worsens outcomes. Dry coverings are preferred.

D. Cover with a clean dry sheet to prevent hypothermia

Burn patients lose heat rapidly due to loss of skin integrity. Covering with a clean, dry sheet helps prevent hypothermia and infection before transfer.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

Correct Answer is C

Explanation

The nurse is caring for a client with 40% full thickness burned total body surface area (TBSA) in the Emergency Department. The nurse is awaiting transfer to a regional burn center within 20 minutes. What is the most appropriate initial wound care management while awaiting transfer?

Correct Answer is D

Explanation

The nurse is preparing to start a transfusion of packed red blood cells. Which IV site should the nurse use?

The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?

The nurse is caring for a client who presents with a chemical burn to the right hand, what should the nurse do first?

The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The marse recognizes that which laboratory test order set will most effectively guide the provider to a diagnosis of DIC?

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?

The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client? (Select All that Apply)

How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

How should the nurse evaluate the client's motor ability and function?