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 A
Explanation
A. Listening to the apical pulse for one full minute provides a more accurate reading of the heart rate and rhythm, especially when the radial pulse is irregular.
B. Recording the findings on the graphic sheet is necessary, but it doesn’t address the irregularity of the pulse.
C. Taking the pulse on the other wrist does not provide the necessary information about the apical pulse.
D. Taking the pulse for one full minute on the other wrist is not necessary unless the pulse is absent on the first wrist.
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.
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