A 48-year-old gardener is driven in by friends after sustaining a chain saw inury to his left arm 10 minutes ago. He complains of severe pain, and blood is dripping from a towel that is wrapped around the patient's wrist. There is a large laceration over the wrist with active bleeding, and the hand distal to the injury is pale and absent of capillary refill. The patient is unable to extend the digits and sensation is absent in the third and fourth digits. The patient appears pale, cool and diaphoretic. Medications: none. Allergies: none. Last dT: 8 years ago PMH: none BP 96/60 Oral Temp 92.2 HR 110 RR 18 What is your triage priority?

emergent

urgent

non-urgent

fast track

Answer and Explanation

The Correct Answer is A

Rationale:
A. Emergent is correct because the patient exhibits life- and limb-threatening conditions. Active hemorrhage, pale and cool distal extremity, absent capillary refill, and loss of motor and sensory function indicate severe arterial bleeding and possible neurovascular compromise. Emergent triage is necessary to prevent exsanguination and permanent limb ischemia.

B. Urgent is incorrect because although urgent conditions require prompt attention, this patient’s vascular compromise and ongoing hemorrhage constitute an immediate threat to life and limb, which is higher priority than standard urgent care.

C. Non-urgent is incorrect because non-urgent patients are stable and can safely wait for assessment; this patient is hemodynamically unstable and at risk for permanent disability.

D. Fast track is incorrect because fast track is for minor, uncomplicated injuries that can be treated quickly; this patient’s injury is severe with active bleeding and neurovascular compromise.

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Correct Answer is ["C","D","E"]

Explanation

Rationale:
A. Increased hematocrit is not expected in fluid overload. Fluid overload causes hemodilution, which typically results in a decreased hematocrit due to dilution of red blood cells in excess plasma volume.
B. Increased temperature is not a characteristic finding of fluid overload. Elevated temperature is more commonly associated with infection or inflammation rather than excess fluid volume.
C. Increased heart rate is expected in fluid overload because the heart must work harder to circulate the increased blood volume. Tachycardia may occur as a compensatory response to maintain adequate cardiac output.
D. Increased blood pressure is a common finding in fluid overload due to the expanded intravascular volume, which increases vascular pressure and workload on the heart.
E. Increased respiratory rate is expected in fluid overload, especially if fluid accumulates in the lungs. Pulmonary congestion or edema leads to impaired gas exchange, prompting tachypnea as the body attempts to improve oxygenation.

A. decreased blood volume B. decreased size of capillary bed C. inadequate cardiac output D. third spacing

Correct Answer is B

Explanation

Rationale:
A. Decreased blood volume is a primary cause of hypovolemic shock. When the body loses blood or plasma, there is insufficient circulating volume to perfuse tissues, leading to cellular hypoxia and organ dysfunction. Causes include hemorrhage, severe dehydration, or fluid loss from burns, all of which reduce oxygen delivery to vital organs.

B. Decreased size of the capillary bed does not cause shock. Shock occurs due to inadequate oxygen delivery to tissues, which results from reduced circulating volume, pump failure, or abnormal distribution of blood (as in distributive shock). While local perfusion might be affected if capillary beds are altered, systemic shock is not triggered simply by a reduction in capillary size. Shock depends on the overall ability of the circulatory system to deliver oxygen to cells, not the anatomical size of capillary networks.

C. Inadequate cardiac output is the hallmark of cardiogenic shock. When the heart cannot pump effectively, perfusion to tissues declines, leading to cellular hypoxia, lactic acidosis, and organ dysfunction. Causes include myocardial infarction, severe heart failure, or arrhythmias that compromise stroke volume.

D. Third spacing occurs when fluid shifts from the intravascular space into interstitial or “third” spaces, as seen in burns, pancreatitis, or severe sepsis. This effectively decreases circulating blood volume, reduces tissue perfusion, and can precipitate hypovolemic-type shock, even though total body fluid may be normal or elevated.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["C","D","E"]

Explanation

Shock can result from all of the following except:

Correct Answer is B

Explanation

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

A patient who was an unrestrained driver in a high-speed, head-on motor vehicle collision presents with dyspnea, tachycardia, hypotension, jugular venous distension, tracheal deviation to the left, and decreased breath sounds on the right side. What is the most likely diagnosis?

A nurse is caring for a client who is experiencing hypovolemic shock. Which of the following blood products should the nurse anticipate administering to this client?

A critical care nurse is planning assessments in the knowledge that patients in shock are vulnerable to developing fluid replacement complications. For what signs and symptoms should the nurse monitor the patient? Select all that apply.

The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions?

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

The development of MODS is confirmed in a patient who manifests