The nurse is caring for a patient in hypovolemic shock as a result of penetrating thoracic trauma. The patient has received 3L of lactated ringers' solution (LR), 2 units of packed red blood cells (PRBCs), 1 unit of fresh frozen plasma (FFP), and 1 unit of platelets. Which assessment finding should the nurse report to the provider immediately?

Blood pressure 102/78

Pulse oximetry 95%

Crackles at bilateral bases

Heart rate 105 beats per minute

Answer and Explanation

The Correct Answer is C

A) Blood pressure 102/78:
This blood pressure is within an acceptable range, especially after resuscitation with fluids and blood products. While hypotension is a concern in hypovolemic shock, this blood pressure is stable and does not indicate an immediate need for intervention. Blood pressure monitoring is essential, but this finding is not as urgent as other options.

B) Pulse oximetry 95%:
A pulse oximetry reading of 95% is generally considered within normal limits for a patient who has undergone resuscitation and is stable. Oxygen saturation levels should be monitored, but this finding does not indicate an immediate need for intervention. Values below 90% would be more concerning, especially in trauma patients, but 95% is acceptable.

C) Crackles at bilateral bases:
The presence of crackles at the bilateral lung bases is a sign of pulmonary edema, which can occur as a result of fluid overload, especially after aggressive resuscitation with fluids like lactated Ringer's solution (LR) and blood products. In hypovolemic shock, rapid infusion of fluids can overwhelm the heart's ability to handle the volume, leading to fluid accumulation in the lungs. This finding is concerning because it can indicate a shift from hypovolemic shock to a state of volume overload, which can worsen respiratory function and lead to acute respiratory distress syndrome (ARDS).

D) Heart rate 105 beats per minute:
A heart rate of 105 beats per minute is slightly elevated but can be expected in a patient who has experienced trauma and is undergoing fluid resuscitation. Tachycardia is often seen in hypovolemic shock as the body compensates for decreased circulating volume. While monitoring the heart rate is important, this finding does not indicate an immediate life-threatening concern compared to crackles in the lungs, which suggest pulmonary edema.

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Correct Answer is B

Explanation

A) Notify the primary care provider with increased urine output
Increased urine output is not directly related to signs or symptoms of infection associated with a tunneled IV catheter, such as a Hickman catheter. While changes in urinary output might indicate renal or other systemic issues, they do not signal a local infection at the insertion site.

B) Assess daily for redness, swelling, or exudate at insertion site weekly
One of the most common complications of a tunneled IV catheter, such as a Hickman, is infection at the insertion site or along the catheter tract. The nurse should instruct the patient to monitor for signs of infection, including redness, swelling, and exudate (pus or drainage) at the insertion site. These signs suggest possible infection, and early detection is critical to preventing more serious complications like sepsis.

C) The primary care provider will monitor hemoglobin and hematocrit values
While monitoring hemoglobin and hematocrit values is important for assessing overall health and blood status, it is not specifically related to monitoring for infection in a client with a tunneled IV catheter. Hemoglobin and hematocrit can provide information about anemia or dehydration but do not directly indicate an infection at the insertion site.

D) To maintain patency, the catheter should be flushed weekly using a 5ml syringe
Although flushing a tunneled IV catheter to maintain patency is important, this response does not directly address infection prevention, which is the focus of the question. Typically, a catheter should be flushed as per specific guidelines (which may include daily or weekly flushing, depending on the clinical setting).

A. Respiratory compromise B. Hypertension C. Septic shock D. Bradycardia

Correct Answer is A

Explanation

A) Respiratory compromise
A spinal cord injury (SCI) at the level of C-3 (cervical spine) results in the loss of function of the diaphragm, which is innervated by the phrenic nerve originating from C-3 to C-5. As a result, the patient is at high risk for respiratory compromise and may require mechanical ventilation. Respiratory failure is a leading cause of death and complications in individuals with high cervical spinal cord injuries, particularly when the injury is at or above C-4.

B) Hypertension
Although spinal cord injuries can cause autonomic dysreflexia (a condition where the body’s autonomic nervous system overreacts to stimuli, leading to dangerously high blood pressure), this condition is more common in individuals with injuries above T6. At C-3, respiratory issues are the primary concern, and hypertension is not the leading cause of complications.

C) Septic shock
Septic shock can occur after any significant injury, especially if the individual develops infections (e.g., from urinary retention, pressure ulcers, or pneumonia). However, septic shock is not the main cause of complications or death related to a C-3 spinal cord injury.

D) Bradycardia
Bradycardia (a slow heart rate) can indeed be a concern in patients with SCI, especially those with injuries at or above the T1 level. However, at the level of C-3, the main cause of complications is respiratory failure, not bradycardia. While bradycardia can occur due to disruption of sympathetic nervous system control, respiratory compromise is the most critical immediate concern.

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The nurse is preparing discharge teaching for a client newly diagnosed with cancer who just had a tunneled IV catheter (Hickman) placed. The nurse would include which information in the teaching plan regarding sign and symptoms of infection?

Correct Answer is B

Explanation

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this level of injury?

Correct Answer is A

Explanation

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