A client who has sustained blunt abdominal trauma is admitted to the ICU. Upon assessment the nurse notices the following vital signs: T-99F; HR- 148: RR-38; B/P-60/40. The client is diaphoretic and restless. The following selections are approved by the ICU physician. What would be the PRIORITY nurse's action?

Auscultate bowel sounds, record the findings and obtain a 12-lead ECG

Initiate the standing prescription for v Dopamine at 16 mcg/kg/minute

Place soft restraints on the upper extremities and sedate as necessary

Lower the head the bed obtain a pulse ox and increase the rate of iv fluids

Answer and Explanation

The Correct Answer is D

A. Auscultate bowel sounds, record the findings, and obtain a 12-lead ECG
While auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.

B. Initiate the standing prescription for Dopamine at 16 mcg/kg/minute
Dopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.

C. Place soft restraints on the upper extremities and sedate as necessary
The client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.

D. Lower the head of the bed, obtain a pulse ox, and increase the rate of IV fluids
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Laterally on the left side

Lateral positioning may not fully prevent contractures.

B. Supine with a pillow under the head

A pillow under the head can cause neck contractures.

C. Semi-Fowler’s without a pillow, right arm & hand elevated

Prevents contractures and promotes drainage of edema.

D. Prone without a pillow

Prone position increases discomfort and risk of respiratory complications.

A. Bend the client's head toward their chest B. Ask the client to extend both arms above their head C. Place the client in supine position D. The nurse will place a hand behind the client's head E. Assist the client to bend their knee 90 degrees

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

Explanation

A. Bend the client’s head toward their chest is correct because Brudzinski’s sign is tested by flexing the client’s neck and observing for an involuntary flexion of the hips and knees, which suggests meningeal irritation.

B. Ask the client to extend both arms above their head is incorrect; this is not part of the test for Brudzinski’s sign.

C. Place the client in a supine position is correct because the test must be done with the client lying flat on their back.

D. The nurse will place a hand behind the client’s head is correct because the nurse gently lifts the client’s head to assess for involuntary hip and knee flexion.

E. Assist the client to bend their knee 90 degrees is incorrect; knee bending is not required for Brudzinski’s sign but is part of Kernig’s sign testing.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is C

Explanation

The nurse is assessing a client for Brudzinskis sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? SELECT ALL THAT APPLY

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

Explanation

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

The nurse in the emergency department is caring for a client with multiple injuries following a motor vehicle crash. The client lost consciousness. has an open fracture of the left tibia, and active bleeding at the fracture site. What is the priority nursing action?

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (Select All that Apply)

The nurse is caring for a client, with no other pertinent medical history, who was burned over 709% Total Body Surface Area (TBSA) and weighs 70kg. Using the Parkland Formula, calculate the amount of intravenous fluid required in the first 8 hours after the burn.

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

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

The client who is experiencing septic shock is started on norepinephrine by intravenous drip via pump. Which frequent assessments should the nurse prioritize while administering this medication? (Select All that Apply)