You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient?

Hypothermia

Bradycardia

Coffee ground emesis

Pain

Answer and Explanation

The Correct Answer is A

Rationale:
A. Hypothermia is correct because rapid infusion of large volumes of crystalloid fluids—especially if the fluids are at room temperature or refrigerated—can lower the patient’s core body temperature. This is particularly important in patients in shock because hypothermia can exacerbate coagulopathy, impair oxygen delivery, and increase the risk of arrhythmias, all of which can worsen outcomes. In addition, critically ill patients are often already at risk for hypothermia due to exposure during resuscitation, impaired thermoregulation, or blood loss. Nursing interventions include monitoring temperature closely, using fluid warmers, applying warming blankets, and assessing for shivering.

B. Bradycardia is incorrect because fluid resuscitation for hypovolemic shock typically increases preload and cardiac output, leading to tachycardia as a compensatory mechanism. Bradycardia is not a common or expected effect of large-volume crystalloid infusion in this context, and if present, it may indicate another problem such as cardiac conduction abnormalities or medication effects.

C. Coffee ground emesis is incorrect because this indicates upper gastrointestinal bleeding, which is not a direct consequence of crystalloid fluid administration. While stress-related mucosal disease can occur in critically ill patients, coffee ground emesis is not an expected sign to monitor specifically due to fluid resuscitation.

D. Pain is incorrect because although a patient may experience discomfort at the IV site or from underlying injuries, pain is not a specific or anticipated effect of large-volume crystalloid infusion. Monitoring for pain is always appropriate, but it is not the priority sign related to this intervention.

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Correct Answer is A

Explanation

Rationale:
A. Airway protection is the top priority in a client with multiple system trauma. Trauma patients are at high risk for airway obstruction due to decreased level of consciousness, facial or neck injuries, blood or vomit in the airway, and cervical spine instability. According to the ABCs of emergency care, a patent airway must be established and maintained first because hypoxia can rapidly lead to brain injury and death. No other interventions are effective if the airway is compromised.
B. Decreasing intracranial pressure is a critical concern in clients with suspected head injury, but it is not the immediate priority until the airway and breathing are secured. Without adequate oxygenation, efforts to manage intracranial pressure will be ineffective and neurological injury will worsen.
C. Stabilizing cardiac arrhythmias addresses circulation, which is important in trauma care, but it comes after airway and breathing have been ensured. Additionally, arrhythmias may be secondary to hypoxia, meaning airway management may correct the underlying cause.
D. Preventing musculoskeletal disability focuses on long-term functional outcomes. While important during recovery and rehabilitation, it is not a priority during the acute, life-threatening phase of trauma management.

A. Assess the capillary refill. B. Check pupillary response to light. C. Evaluate chest expansion. D. Assess pulses.

Correct Answer is C

Explanation

Rationale:
A. Assessing capillary refill evaluates peripheral perfusion but does not take priority over airway and breathing assessment. It is important for circulation assessment but comes after ensuring adequate ventilation.

B. Checking pupillary response provides information about neurological status and potential brain injury, but neurological assessment is not the first priority in trauma unless airway or breathing is compromised.

C. Evaluating chest expansion addresses airway and breathing, which are the first priorities according to the ABCs (Airway, Breathing, Circulation). Multiple injuries from trauma can compromise ventilation due to rib fractures, pneumothorax, or flail chest. Ensuring effective chest expansion and oxygenation is critical to prevent hypoxia and further organ injury.

D. Assessing pulses evaluates circulation and is important in trauma care, but it is secondary to airway and breathing assessment. Hypoxia poses a more immediate threat to life than reduced peripheral perfusion in the early stages of trauma management.

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You are precepting a new graduate nurse in the ICU. You are collaborating in the care of a patient who is receiving large volumes of crystalloid fluid to treat hypovolemic shock. In light of this intervention, for what sign would you teach the new nurse to monitor the patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

Correct Answer is A

Explanation

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

Correct Answer is C

Explanation

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