A 45-year-old patient presents to the trauma unit after a gunshot wound (GSW) to the abdomen. The patient has a temperature of 92 degrees Fahrenheit, is restless and confused, and has large amount of blood noted from the nasogastric (NG) tube as well as from the indwelling urinary catheter. Which additional assessment finding likely causes death within the first 24 hours following this injury?

Heart rate of 130 beats per minute

PH of 7.21 (normal 7.35-7.45)

Serum potassium 5.7 mEq/L (normal 3,5-5.3)

Platelet count 200,000 (normal 150,000-450,000)

Answer and Explanation

The Correct Answer is B

A) Heart rate of 130 beats per minute
A heart rate of 130 beats per minute is tachycardia, which is often a compensatory response to injury, particularly in cases of trauma, blood loss, or shock. It is common in the initial phase after trauma as the body attempts to compensate for decreased blood volume or oxygen delivery. However, tachycardia alone is not typically fatal in the immediate post-injury period and can often be managed.

B) pH of 7.21 (normal 7.35–7.45)
A pH of 7.21 indicates acidosis, which is life-threatening and typically arises from shock, blood loss, or severe trauma. Acidosis occurs when the body is unable to compensate for lactic acid or other metabolic byproducts that accumulate due to insufficient oxygen delivery to tissues. In the case of a gunshot wound to the abdomen, there is a high risk of internal bleeding, hypoperfusion, and hypoxia, all of which can lead to metabolic acidosis. Severe acidosis can cause organ failure, particularly affecting the heart, kidneys, and brain.

C) Serum potassium 5.7 mEq/L (normal 3.5–5.3)
A serum potassium of 5.7 mEq/L is elevated, but it is moderately high and not typically life-threatening unless it reaches much higher levels (e.g., >6.0 mEq/L), which can cause cardiac arrhythmias. Elevated potassium can occur due to cellular injury (e.g., muscle trauma or rhabdomyolysis), but it would need to be corrected to prevent complications like arrhythmias.

D) Platelet count 200,000 (normal 150,000–450,000)
A platelet count of 200,000 is within the normal range (150,000–450,000) and does not indicate a problem with coagulation. The blood loss and the NG tube hemorrhage mentioned in the scenario suggest that the patient may be at risk for bleeding, but a platelet count in the normal range suggests that the body’s ability to form clots is likely intact.

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Correct Answer is D

Explanation

A) Isolate away from the family in a separate room:
Isolation is unnecessary for a client with HIV. HIV is primarily transmitted through specific bodily fluids such as blood, semen, vaginal fluids, and breast milk. The virus is not transmitted through casual contact, so there is no need for the client to isolate from their family.

B) Retest for opportunistic infections monthly:
While it is important for clients with HIV to be regularly monitored for opportunistic infections, monthly testing is not typically necessary unless specific symptoms or clinical indicators warrant it. Routine follow-up with a healthcare provider to monitor CD4 count, viral load, and overall health status is essential, but frequent opportunistic infection screening is not a general requirement.

C) Live alone to prevent any transmission of HIV:
There is no need for individuals with HIV to live alone to prevent transmission. As mentioned earlier, HIV is not spread through casual contact, so the client can live with family members without concern, as long as they follow proper precautions regarding handling blood or bodily fluids.

D) Clean any of their blood that spills with bleach:
Blood and other bodily fluids containing HIV are the primary sources of transmission. If any blood spills, cleaning the area with bleach (a disinfectant known to destroy HIV) is an important safety measure to reduce the risk of transmission. The client should also be taught to use gloves when cleaning blood spills, and to follow universal precautions when handling items contaminated with blood or other potentially infectious fluids.

A. increased cardiac output. B. inadequate tissue perfusion. C. fluid overload or deficit D. vasoconstriction of vasculature.

Correct Answer is B

Explanation

A) Increased cardiac output:
While cardiac output is an important factor in shock management, the primary goal of nursing care is not specifically to increase cardiac output. Shock typically involves inadequate tissue perfusion, which may be caused by a variety of factors including low cardiac output, vasodilation, or fluid imbalance. The focus of nursing care is to restore adequate perfusion to tissues, which may involve improving cardiac output as part of a larger therapeutic strategy.

B) Inadequate tissue perfusion:
The primary goal in the treatment of shock is to restore adequate tissue perfusion, as shock is defined by a failure of the circulatory system to supply sufficient oxygen and nutrients to the body's tissues and organs. Inadequate tissue perfusion can lead to organ dysfunction and, if not addressed, can result in organ failure and death. Nursing interventions are aimed at improving perfusion through fluid resuscitation, vasoactive medications, and other strategies to ensure that oxygen and nutrients are delivered to vital organs.

C) Fluid overload or deficit:
Managing fluid status is crucial in shock, as fluid imbalance (either overload or deficit) can exacerbate the condition. However, fluid overload or deficit is not the primary focus; rather, it is one aspect of managing inadequate tissue perfusion. For example, in hypovolemic shock, the nurse would manage fluid deficit, while in cardiogenic shock, the focus would be on optimizing fluid balance without causing overload.

D) Vasoconstriction of vasculature:
While vasoconstriction can be a compensatory mechanism in certain types of shock (e.g., hypovolemic shock), the primary goal is not to induce vasoconstriction per se. In some cases, vasodilation may occur (as in septic shock), and vasoconstriction could be harmful. The goal is to optimize the vascular tone and perfusion, which may involve vasodilation or vasoconstriction depending on the type of shock.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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