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The triage nurse is assessing a victim of a stab wound. According to the
paramedics, the victim was stabbed by a male attacker. The knife blade is 6 inches
(7.2 cm) in length and 1 inch (2.5 cm) in width. The "point of entry" of the stab
wound is two inches above and left of the victim's xiphoid process. Which vital
organ(s) are at an increased risk of being in the direct path of injury? - CORRECT
ANSWER Heart
Lungs
Diaphragm
What way do females stab? - CORRECT ANSWER Downwards
What way do males stab? - CORRECT ANSWER Upwards
A client reports to the nurse feeling achy and weak, being tired and coughing all the
time, frequent headaches and experiencing night sweats. The client's assessment
is significant for crackles scattered throughout the lungs, dependent peripheral
edema +3/+4, S3 and S4 heart sounds, temperature of 102.4° F(39.1° C), heart
rate of 110 beats/minute, respirations of 20 breaths/minute, and blood pressure of
105/60 mmHg with a mean arterial pressure of (75). Which diagnostic procedure
should the nurse prepare to do first? - CORRECT ANSWER Blood culture
Define: Infective endocarditis - CORRECT ANSWER Infection of the
endocardial surface of the heart, usually the heart valves
What indicates ineffective endocarditis? - CORRECT ANSWER Edema & S1/S3
sounds
According to the paramedic's report, the victim of a motor vehicle collision was
sitting in the passenger seat on the left side of the vehicle. The vehicle was stopped
,CRITICAL CARE 1 2023 QUESTIONS
AND ANSWERS ALREADY PASSED A+
at a traffic light when the vehicle was hit on the left side by another vehicle traveling
at speeds exceeding 60 mph (97 kmh). The client reports slight tenderness and
achiness on (L) side of thorax and body. The significant assessment findings
include: weak and thready pulse; diffuse abdominal pain, tenderness and guarding
present upon palpation; skin is diaphoretic and extremities cool to touch, capillary
refill +4 in extremities, and bruising is present in the (L) flank area and progresses
towards the abdomen. Vital signs are temperature- 97.2° F (36.2° C), pulse- 110
beats/minute, respirations- 22 breaths/minute, blood pressure 84/46 mmHg, MAP-
(57), and pulse oximetry 90% on 2 lpm O2 via nasal cannula. - CORRECT
ANSWER Fractured liver & ruptured spleen
The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanicallly
ventilated. The ABG results are pH- 7.52; paCO2- 30 mmHg; HCO3- 28 mEq/liter.
How should the nurse interpret this blood gas? - CORRECT ANSWER
Respiratory alkalosis
Define: Respiratory alkalosis - CORRECT ANSWER HCO3 & pH is increased
while the CO2 is decreased
What is the effect if blood sugar continues to rise? - CORRECT ANSWER
Change in level of consciousness
What precaution should a patient be on with a high sodium? - CORRECT
ANSWER Seizure precautions
Why do people with diabetes have an increased urinary output? - CORRECT
ANSWER Low ADH
, CRITICAL CARE 1 2023 QUESTIONS
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What is the effect of a low ADH? - CORRECT ANSWER Dehydration &
increased serum Sodium
A client with syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
is admitted to the intensive care unit with a serum sodium level of 112 mEq/L or
mmol/L. Which protocol prescription should the nurse implement first? -
CORRECT ANSWER Obtain serum sodium every 4 hours
The nurse is caring for a client who is demonstrating signs of impending death. The
family is experiencing emotional distress as the client's condition declines. Which
information should the nurse provide the family to facilitate the process? -
CORRECT ANSWER Encourage the family to give the patient permission to die
The nurse is caring for a client with severe sepsis related to a ruptured
appendix.The clientis diaphoretic and reports lower extremity spasms. The nurse
observes respirations that are uneven and labored. Arterial blood gas (ABG) results
are pH 7.60, PaCO2 25 mmHg, HCO3 24 mEq/L, and PaO2 24 mmHg. Which
assessment finding warrants immediate intervention by the nurse? - CORRECT
ANSWER Intercostal muscle contraction
Define: Intercostal muscle contraction - CORRECT ANSWER Critical sign of
respiratory muscle fatigue which is likely to lead to acute respiratory failure
Define: Cistacurium - CORRECT ANSWER Paralytic during surgery
A client who experienced an intracranial hemorrhage is receiving cistracurium to
induce a pharmacological state of paralysis. Which intervention should the nurse
implement during the therapeutic paralysis? - CORRECT ANSWER Administer
a sedating medication