Question 1

A patient, admitted with multiple injuries, is prescribed to receive an intravenous colloid solution. Which one of the following solutions would be appropriate for the nurse to infuse?

Accepted Answer

The patient's multiple injuries may have resulted in fluid loss or shock, requiring replacement with a colloid solution. 25% albumin is a colloid solution that helps increase plasma volume and provides immediate intravascular support, making it an appropriate choice for the patient's condition. The other options are not colloid solutions and may not provide the necessary support to address the patient's fluid loss and shock.

Question 2

The nurse, caring for a patient who sustained a traumatic injury several days ago, notes that the patient is hypotensive, oliguric, and has cool, pale skin and acidosis. The nurse understands that these are manifestations of which of the following?

Accepted Answer

The symptoms given are classic signs and symptoms of hypovolemic shock, which occurs when there is a significant loss of blood volume or fluids. The hypotension (low blood pressure) is a result of decreased cardiac output due to the loss of blood volume. Oliguria (decreased urine output) is a sign that the kidneys are not receiving enough blood to function properly. Acidosis indicates that the body is not effectively removing waste products and that vital organs, such as the brain, may not be receiving enough oxygen. The cool, pale skin is due to the body's compensatory mechanisms redistributing blood flow to vital organs instead of the skin.

Question 3

An adult patient who has died from traumatic injuries is an organ donor. Which of the following should the nurse do when caring for this patient?

Accepted Answer

Maintaining a systolic blood pressure of 90 mmHg is important in order to ensure perfusion to the organs that will be donated. This will help to maintain their viability and increase the likelihood of successful transplantation. The other options are not appropriate and could potentially harm the organs, making them unsuitable for transplant. Oxygen saturation should be kept above 90%, providing intravenous fluids should be based on the patient's individual needs, and external cardiac compressions could damage the organs.

Question 4

A patient who was a victim of rape six months ago comes to an outpatient clinic for the treatment of post-traumatic stress disorder. Which data collected during the patient's assessment would indicate a manifestation associated with this disorder?

Accepted Answer

Severe nightmares related to the traumatic event are a common manifestation of post-traumatic stress disorder. Choice B is incorrect because anger and shock are common reactions to trauma. Choice C is incorrect because patients with post-traumatic stress disorder may turn to drugs or alcohol as a coping mechanism. Choice D is incorrect because while having a supportive family can be helpful, it is not necessarily an indicator of post-traumatic stress disorder.

Question 5

Which of the following assessment findings would be seen in a patient who experienced a traumatic brain injury and is being evaluated for brain death?  Select all that apply.

Accepted Answer

A patient who has experienced a traumatic brain injury and is being evaluated for brain death will have certain assessment findings that indicate the absence of brain function. These can include the absence of gag or corneal reflex, absence of oculovestibular reflex, and apnea with a PaCO2 of 66 mmHg or greater. Response to deep stimuli would indicate some level of brain function, while toxic metabolic disorders may affect brain function but are not specific to brain death evaluation.

Question 6

The nurse wants to calculate a patient's mean arterial pressure. Which of the following vital signs would the nurse use to make this calculation?

Accepted Answer

Mean arterial pressure (MAP) is calculated using the patient's blood pressure. MAP is defined as the average arterial pressure during a cardiac cycle and is important in assessing tissue perfusion.

Question 7

The nurse, planning care for a patient diagnosed with shock, would include which of the following interventions for the nursing diagnosis of Anxiety?

Accepted Answer

Anxiety is a common response to shock and reducing stimuli and providing pain medication can help alleviate this symptom. Assessing blood pressure and heart rate, monitoring central venous pressure, and assessing bowel sounds are important interventions for shock management but do not directly address the nursing diagnosis of Anxiety.

Question 8

Which of the following interventions would be essential for the nurse to assess first for a patient admitted with severe facial injuries?

Accepted Answer

Assessing for signs of stridor, cough, or respiratory distress is the priority for a patient with severe facial injuries as airway management is the most critical aspect of initial care. Other interventions can be addressed once the airway is stabilized.

Question 9

A patient is brought to the emergency department with gunshot wounds to the abdomen and lower extremities. To protect the chain of evidence for these injuries, which of the following should the nurse do?

Accepted Answer

Removing the patient's clothing and placing it in a breathable bag is the best option for preserving the chain of evidence for gunshot wounds. This will help to prevent any potential contamination or loss of evidence from the clothing. Covering the patient's hands with plastic bags may be appropriate for other types of evidence, but not for gunshot wounds. Cutting off the patient's clothing and bathing the skin and wounds should be avoided to preserve the evidence. Placing clothing and other patient items on a bedside table could result in contamination or loss of evidence.

Question 10

A patient with traumatic injuries has lost approximately 300 mL of blood. The nurse realizes that which of the following will most likely be assessed in this patient?

Accepted Answer

A slight increase in heart rate is a common compensatory mechanism in response to blood loss. Nonpalpable peripheral pulses and narrowing pulse pressure are more significant signs of hypovolemia and shock. An increase in blood glucose level may be seen later in the compensatory stage but would not be the most immediate assessment finding.

Question 11

A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. The nurse realizes that the solution of choice for this patient would be which of the following?

Accepted Answer

Ringer's lactate is the solution of choice for patients with hypovolemic shock as it helps to replace lost volume, restore electrolyte balance, and support the cardiovascular system. Dextrose solutions are not recommended for hypovolemic shock as they can lead to hyperglycemia and fluid shifts between compartments.

Question 12

The nurse is providing medications to increase a patient's system vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion?

Accepted Answer

Mean arterial pressure (MAP) is a measure of the average pressure in the arteries during one cardiac cycle. It is calculated by adding one-third of the pulse pressure to the diastolic blood pressure. MAP is a good indicator of tissue perfusion, as it reflects the pressure gradient that drives blood flow to the tissues. A MAP of 60 mmHg is generally considered to be the minimum necessary for adequate tissue perfusion.

Question 13

The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. Which of the following should the nurse do when providing this medication?

Accepted Answer

Intravenous nitroglycerin should be administered using an infusion pump to ensure accurate dosing and prevent rapid fluctuations in blood pressure. PVC tubing is not recommended for use with nitroglycerin due to the potential for absorption of the medication by the tubing itself. Nitroglycerin should be used within 24 hours of reconstitution, not 8 hours. Patients receiving nitroglycerin may experience dizziness and hypotension, and should remain in bed with assistance if necessary.

Question 14

A patient is diagnosed with a pneumothorax. The nurse realizes that unless this is treated, the patient is at risk for developing which of the following types of shock?

Accepted Answer

A pneumothorax is a type of obstructive shock. It occurs when air enters the pleural cavity, causing pressure on the lung and impairing its ability to expand and fill with air, which can cause a decrease in cardiac output and oxygenation. This can lead to hypoxia, respiratory distress, and eventually shock. Immediate medical attention is needed to treat a pneumothorax to prevent the development of shock.

Question 15

A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which of the following would the nurse assess as an effect of this medication?

Accepted Answer

Dobutamine is a sympathomimetic medication that stimulates beta-1 receptors in the heart, leading to increased heart rate and contractility. This helps to improve cardiac output and blood pressure in patients experiencing shock. Reduced heart rate, decreased respiratory rate, and decreased blood pressure are not expected effects of dobutamine.

Question 16

An elderly patient is diagnosed with E. coli in the blood stream. If not treated, the nurse realizes this patient is at risk for developing which of the following types of shock?

Accepted Answer

Distributive shock, specifically septic shock, can occur due to a severe infection like E. coli in the bloodstream, leading to widespread inflammation and blood vessel dilation, impairing blood flow and oxygen delivery to tissues.

Question 17

The spouse of a patient admitted with severe spinal cord injuries tells the nurse that she believes her husband is going to recover since he continues to make movements that occur without stimulation. Which of the following should the nurse explain to the spouse?

Accepted Answer

The nurse should explain that the patient's movements may be reflexes but they do not necessarily indicate brain function or predict recovery. It is important for the spouse to understand the limitations of these movements in predicting outcomes for their loved one.

Question 18

A patient hospitalized with traumatic injuries has the nursing diagnosis of Impaired Physical Mobility. Which of the following interventions would be appropriate for this patient?

Accepted Answer

Active range of motion exercises help maintain joint function and prevent muscle atrophy, which is appropriate for a patient with impaired physical mobility.

Question 19

The nurse suspects that a patient diagnosed with a myocardial infarction is developing cardiogenic shock when which of the following is assessed?

Accepted Answer

Jugular vein distention is a sign of elevated central venous pressure, which is characteristic of cardiogenic shock. Warm extremities, laryngospasm, and urticaria are not indicative of cardiogenic shock.

Question 20

A patient has an estimated blood loss of two liters and has a mean arterial pressure ranging between 30 and 40 mmHg. If this patient's hemodynamic status is not corrected, the nurse realizes that which of the following can occur?

Accepted Answer

Failure of the sodium-potassium pump can occur due to inadequate perfusion and oxygenation of tissues, leading to cellular energy failure. This is a consequence of significant blood loss and low mean arterial pressure, which impairs the delivery of oxygen and nutrients to cells.

Quiz 11: Nursing Care of Patients Experiencing Trauma and Shock