The nurse in the ICU is assessing a client who sustained blunt abdominal trauma. The client has received 3 liters of crystalloid solution in the Emergency Department and 5 units of Packed Red Blood Cells (PRBCs) in the Operating Room. What assessment finding would the nurse report to the physician IMMEDIATELY?
Respiratory rate 24 and bloody drainage in the NG tube
Client is oriented to name and place but not the date
Blood pressure 4/48 and urine output of 24 mL/hour
Hypo-active bowel sounds and tachycardia
The Correct Answer is C
A. Respiratory rate 24 and bloody drainage in the NG tube
While an increased respiratory rate and bloody drainage are concerning, they may not indicate an immediate life-threatening situation compared to the other options.
B. Client is oriented to name and place but not the date
This suggests some level of confusion or altered mental status, which is important but not necessarily an immediate threat.
C. Blood pressure 40/48 and urine output of 24 mL/hour
This indicates severe hypotension and inadequate perfusion, which are signs of ongoing shock and possibly continued internal bleeding. Immediate intervention is critical.
D. Hypo-active bowel sounds and tachycardia
Hypo-active bowel sounds and tachycardia are concerning and suggestive of shock, but they are not as immediately life-threatening as severely low blood pressure and low urine output.
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Related Questions
Correct Answer is C
Explanation
A. Initial stage of septic shock
Septic shock typically presents with warm, flushed skin in the early phase due to vasodilation. This client has cold and clammy skin, which is more consistent with hypovolemic shock.
B. Refractory stage of obstructive shock
Obstructive shock (e.g., from cardiac tamponade or pulmonary embolism) would present with jugular vein distention, muffled heart sounds, or severe respiratory distress, which are not seen in this case.
C. Progressive stage of hypovolemic shock
The client has classic signs of hypovolemic shock due to fluid loss (nausea, vomiting, diarrhea). The progressive stage is indicated by hypotension, tachycardia, and end-organ dysfunction (altered mental status, cool/clammy skin).
D. Compensatory stage of diabetic shock
"Diabetic shock" is not a standard classification of shock. The compensatory stage would still have an adequate blood pressure due to SNS activation, but this patient already has profound hypotension.
Correct Answer is D
Explanation
A. Prepare for immediate abdominal surgery
There is no indication of active hemorrhage or peritonitis at this point. Further assessment is needed before deciding on surgery.
B. Determine if there are any allergies to food or drugs
Allergy history is important, but it is not the immediate priority for this client.
C. Administer antibiotics as ordered after culture results are available
Antibiotics may be needed if infection is suspected, but the priority is assessing kidney function due to the risk of rhabdomyolysis from muscle breakdown.
D. Obtain a urine specimen
Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. The urine should be tested for myoglobinuria (tea-colored urine), hematuria, or kidney injury markers.
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