The Operating Room (OR) nurse is preparing to give report to the Intensive Care Unit (ICU) nurse on a patient who has had surgery after suffering penetrating chest and abdominal trauma. What should the nurse include in the report? (Select All that Apply.)

Description of injury, vital signs during surgery, and current vital signs

Description of operative procedure and patient tolerance

Total intake and output (IV fluids, blood products, urine/chest tube output, blood loss)

Presence of the patients spiritual advisor and family

Medications administered during surgery and IV access sites

Answer and Explanation

Correct Answer : A,B,C,E

A) Description of injury, vital signs during surgery, and current vital signs:
This information is crucial for the ICU nurse to understand the nature of the injury, how the patient responded during surgery, and their current hemodynamic status. Vital signs during surgery provide insight into the patient's cardiovascular stability and response to anesthesia, blood loss, and interventions. Current vital signs are important to monitor for any postoperative complications.

B) Description of operative procedure and patient tolerance:
The ICU nurse needs to know the details of the surgery performed, such as the type of trauma repair and any complications that may have occurred during the procedure. Understanding how the patient tolerated the surgery (e.g., any complications such as hypotension or arrhythmias) is important for planning post-operative care and anticipating potential issues in the ICU.

C) Total intake and output (IV fluids, blood products, urine/chest tube output, blood loss):
Tracking fluid balance is critical in trauma patients, especially those who have suffered significant blood loss. IV fluids, blood products, and other inputs (such as urine and chest tube output) provide vital information on the patient's circulatory status and renal function. Blood loss is also important to monitor, as it may need to be replaced, and fluid status affects the patient's recovery.

D) Presence of the patient's spiritual advisor and family:
Although family presence can be an important part of patient care, especially in a trauma situation, it is not essential information for the ICU nurse to receive during a report. While the ICU nurse may ask for family updates and visitor information, the focus of the report should be on the patient's clinical status and post-operative needs.

E) Medications administered during surgery and IV access sites:
The ICU nurse must know the medications administered during surgery, especially anesthesia agents, antibiotics, and analgesics, to understand their effects and anticipate any needed follow-up care, such as pain management or monitoring for adverse reactions. Knowing the IV access sites (e.g., central line, peripheral IV) is important for administering medications, fluids, and for monitoring potential complications related to vascular access.

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Correct Answer is D

Explanation

A) Hypoglycemic event often develops:
Phenytoin is an anticonvulsant, and while it can affect glucose metabolism, hypoglycemia is not a typical consequence of abruptly stopping the drug. This is not a primary concern when discontinuing phenytoin therapy. Hypoglycemia is more commonly associated with medications like insulin or sulfonylureas, not anticonvulsants like phenytoin.

B) Physical dependency on the drug develops over time:
Phenytoin does not cause physical dependence in the way that some other substances (e.g., alcohol, opioids) can. While the body can become used to a medication over time, and withdrawal symptoms can occur, the risk of physical dependence is not the main reason why phenytoin should not be stopped suddenly.

C) A heart block is likely to develop:
Phenytoin is known to have effects on cardiac conduction, and it can cause heart rhythm disturbances like bradycardia or a prolonged PR interval, especially with toxicity. However, the risk of a heart block developing due to abrupt discontinuation of phenytoin is not the primary concern.

D) Status epilepticus may develop:
The most serious risk of suddenly stopping phenytoin, or any anticonvulsant, is the potential for status epilepticus. Status epilepticus is a medical emergency where seizures occur continuously without recovery in between, which can be life-threatening. Abruptly discontinuing phenytoin can lead to a rebound increase in seizure activity, which can result in status epilepticus.

A. Intestines B. Liver C. Spleen D. Stomach

Correct Answer is C

Explanation

A) Intestines:
While abdominal trauma can affect the intestines, Kehr's sign, Cullen's sign, and Gray Turner's sign are more commonly associated with damage to the spleen rather than the intestines. Kehr's sign, in particular, is a hallmark of splenic injury, with pain referred to the left shoulder due to diaphragmatic irritation from blood in the peritoneum.

B) Liver:
Liver injuries often present with right upper quadrant pain, jaundice, and elevated liver enzymes. While liver injuries can cause internal bleeding, Cullen's and Gray Turner's signs are more closely associated with retroperitoneal bleeding from the spleen rather than liver injuries. Kehr's sign, which is left-sided shoulder pain, would not typically indicate a liver injury.

C) Spleen:
The spleen is the most likely abdominal organ affected in this case due to the left-sided rib fractures. When the spleen is injured (often as a result of blunt trauma), it can cause intraperitoneal hemorrhage. This bleeding can irritate the diaphragm, leading to Kehr's sign, which presents as left shoulder pain. Additionally, Cullen's sign (periumbilical bruising) and Gray Turner's sign (flank bruising) are indicative of retroperitoneal bleeding, which can occur with splenic rupture or laceration.

D) Stomach:
While stomach injuries can occur with blunt abdominal trauma, they are less likely to cause the signs and symptoms seen in this patient (Kehr's, Cullen's, and Gray Turner's signs). Stomach trauma typically leads to pain and potential perforation, but it doesn't often cause the peritoneal bleeding patterns seen with splenic injuries.

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The Operating Room (OR) nurse is preparing to give report to the Intensive Care Unit (ICU) nurse on a patient who has had surgery after suffering penetrating chest and abdominal trauma. What should the nurse include in the report? (Select All that Apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client newly diagnosed with a seizure disorder about phenytoin sodium therapy. What information should the nurse stress regarding the client stopping the drug suddenly? The drug should not be stopped abruptly because:

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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