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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Wearing sunglasses while symptomatic
Sunglasses reduce photophobia, but they do not prevent corneal damage from dryness.
B. Applying an eye patch before sleep
Bell's palsy affects cranial nerve VII (facial nerve), leading to incomplete eye closure. This can cause corneal abrasions and dryness. An eye patch at night prevents corneal injury.
C. An antihistamine eye drop
Antihistamine eye drops may dry out the eye further, worsening the risk of corneal injury.
D. Antibiotic ophthalmic ointment
Antibiotics are not necessary unless an infection is present. Lubricating drops or artificial tears are more appropriate.
Correct Answer is B
Explanation
A. Control dysrhythmias and decrease the heart rate
Controlling dysrhythmias is important, but decreasing heart rate is not always the goal, as a compensatory tachycardia may be necessary for perfusion.
B. Decrease cardiac workload and increase systemic perfusion
Cardiogenic shock results from impaired cardiac output. The goal is to reduce the heart’s workload (e.g., by reducing afterload) while improving systemic perfusion.
C. Improve oxygen exchange and decrease urinary output
Oxygenation is important, but decreased urinary output indicates poor renal perfusion and worsening shock, which is not a goal of treatment.
D. Decrease the blood pressure and respiratory rate
In cardiogenic shock, blood pressure is already low. The goal is to maintain adequate perfusion, not to further reduce BP.
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