When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:
increase in temperature.
decrease in pulse.
decrease in blood pressure.
decrease in respirations.
The Correct Answer is C
A. Temperature often decreases in cases of severe blood loss due to shock and hypothermia.
B. A decrease in pulse is unlikely in severe blood loss. The body compensates with an increased heart rate.
C. A decrease in blood pressure is expected in cases of significant blood loss, as the body struggles to maintain adequate circulation.
D. Respirations may increase in response to blood loss, not decrease, as the body attempts to increase oxygen intake.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While extremity inspection is important, it is not as directly related to assessing back pain as evaluating the back itself.
B. Auscultating the lungs is essential in respiratory assessments but is not the priority when examining a patient with back pain.
C. Percussion of the flank areas is a key part of the physical examination for back pain, particularly if there are concerns of kidney involvement or other internal issues causing discomfort.
D. Bowel sounds are not directly related to back pain unless gastrointestinal issues are suspected.
Correct Answer is D
Explanation
A. Temperature monitoring is important but not a top priority when a patient is receiving opiates unless there is suspicion of infection.
B. Pulse monitoring is also important but does not immediately indicate issues with opiate use.
C. Blood pressure is influenced by opiate use, but the primary concern is respiratory function due to the risk of respiratory depression.
D. Respirations should be closely monitored because opiates can significantly depress the respiratory system, leading to hypoventilation or respiratory arrest, which is the most critical risk.
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