How it Works
Try Naxlex NCLEX-RN (Free-Trial)

Exhibits

Highlight the findings that require immediate follow up.

Admitted client. Vital signs: heart rate 128 beats/minute, rhythm sinus tachycardia, respiratory rate 14 breaths/minute, oxygen saturation 100% on 40% fraction of inspired oxygen, temperature 96.9° F (36.1° C), blood pressure 90/79 mm Hg. Pulse pressure calculated to be less than 40 mm Hg. The client's surgical dressing is clean and dry. Ecchymosis noted on the abdomen around the dressing. The client has a peripheral intravenous line in the right forearm and one in the left hand. The client also has a right subclavian central venous catheter that is infusing propofol and intravenous fluids. Heart sounds are regular. The skin is pink. Capillary refill is 6 seconds. Radial pulses are equal bilaterally. Lung sounds are clear and equal bilaterally. The client has an indwelling urinary catheter in place. No urine noted. The client has no visitors at this time. The social worker is attempting to contact family members.

A.

heart rate 128 beats/minute, rhythm sinus tachycardia

B.

temperature 96.9° F (36.1° C)

C.

blood pressure 90/79 mm Hg

D.

Pulse pressure calculated to be less than 40 mm Hg

E.

The client's surgical dressing is clean and dry

F.

Ecchymosis noted on the abdomen around the dressing

G.

Capillary refill is 6 seconds

H.

Radial pulses are equal bilaterally

I.

Lung sounds are clear and equal bilaterally

J.

No urine noted

Answer and Explanation

The Correct Answer is ["A","C","D","E","G","H","J"]

  • Heart rate 128 beats/minute: This is sinus tachycardia and indicates the body is compensating for blood loss or stress. In trauma, especially with known internal bleeding, this is a warning sign of hypovolemia and early shock.
  • Blood pressure 90/79 mm Hg: This is hypotension, and in combination with tachycardia, it strongly suggests poor perfusion and possible hemorrhagic shock. It requires immediate fluid resuscitation and evaluation.
  • Pulse pressure less than 40 mm Hg: A narrowed pulse pressure reflects low stroke volume, which is common in hypovolemia. It supports the diagnosis of possible ongoing internal bleeding and cardiovascular compromise.
  • Capillary refill is 6 seconds: Normal capillary refill is under 2 seconds. A 6-second refill shows significantly delayed peripheral perfusion, a hallmark of systemic hypoperfusion or shock.
  • No urine noted: Absence of urine in a catheterized trauma patient suggests reduced renal perfusion, which may be a sign of advancing shock and impending organ dysfunction.
  • Temperature 96.9°F (36.1°C): Mild hypothermia in trauma is dangerous. It can worsen coagulopathy and bleeding, contributing to the trauma triad. It should be treated with active warming interventions.
  • Ecchymosis noted on the abdomen around the dressing: Bruising in this area, especially with known liver and spleen lacerations, suggests ongoing or worsening internal bleeding. This physical sign must be monitored for expansion or tenderness.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

A. It prevents mouth infections when an inhaler is used: While spacers can reduce oral side effects like thrush with steroid inhalers, preventing mouth infections is not the primary reason for using a spacer with bronchodilators.

B. It allows the medication to slowly enter the lungs: A spacer doesn't slow down medication entry; it holds the medication briefly, allowing the client more time to inhale effectively, but the primary goal is improving delivery efficiency.

C. It increases the effectiveness of the medication: Using a spacer improves medication delivery by reducing the amount deposited in the mouth and throat and maximizing the dose that reaches the lungs, making treatment more effective.

D. It allows time to inhale the entire dispensed dose: Although a spacer gives a few extra seconds to inhale the medication, the main advantage is optimizing deposition in the lungs rather than just allowing more time.

Correct Answer is A

Explanation

A. Transfuse Type A negative blood until Type AB negative is available: In an emergency, when AB negative blood is unavailable, Type A Rh-negative blood is an acceptable alternative for an AB negative recipient. It shares compatible A antigens and lacks the Rh factor, minimizing transfusion reaction risk.

B. Recheck the client's hemoglobin, blood type, and Rh factor: This information has already been determined, and delaying transfusion in a critical situation could worsen hypoxia and risk death.

C. Administer normal saline solution until Type AB negative is available: Saline can temporarily support circulation, but it does not address the critical oxygen-carrying deficiency from severe anemia, which requires immediate blood transfusion.

D. Obtain additional consent for administration of Type A negative blood: In life-threatening emergencies, blood transfusions may proceed under implied consent, particularly when delay would place the client at risk.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register