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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?

A.

Respiratory rate 24 and bloody drainage in the NG tube

B.

Client is oriented to name and place but not the date

C.

Blood pressure 4/48 and urine output of 24 mL/hour

D.

Hypo-active bowel sounds and tachycardia

Answer and Explanation

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 ["70"]

Explanation

  • Formula: Dose = Weight (kg) × 80 units/kg
  • 5600 units ÷ 80 units/kg = 70 kg

Correct Answer is A

Explanation

A. Fluid resuscitation

Burns covering a large TBSA result in massive fluid loss due to increased capillary permeability, leading to hypovolemic shock. Fluid resuscitation with lactated Ringer’s solution using the Parkland formula is the priority to restore intravascular volume and prevent organ failure.

B. Transfer to a burn center

While this patient requires specialized burn care, the immediate priority is fluid resuscitation. After initial stabilization, transfer to a burn center can be arranged.

C. Application of sterile dressings

Wound care is important, but it is not the priority in the emergent phase. Restoring circulation and preventing shock take precedence.

D. Administer morphine 8 mg IV

Pain management is crucial, but it is secondary to restoring intravascular volume and preventing hypovolemic shock.

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