Page 459 - Critical Care Nursing Demystified

444 CRITICAL CARE NURSING DeMYSTIFIED

10. A CAT scan reveals that an individual has sustained an SAH (subarachnoid hem-
orrhage). Which physical signs will best illustrate to the nurse a probable
increase in ICP?
A. Absent verbal responses, decreased level of consciousness
B. Heightened awareness of the patient’s environment
C. Spontaneous withdrawal from painful stimuli
D. Slurred speech, lateral eye deviation

Chapter 6

1. A nurse is performing an assessment of a trauma victim. In what phase of trauma
care would the nurse examine each body region for additional injuries?
A. Definitive care
B. Secondary survey
C. Primary survey
D. Prehospital stabilization

2. A nurse is to administer massive transfusions to a patient who has been admit-
ted to the ECU post industrial accident in profound hemorrhagic shock. After Downloaded by [ Faculty of Nursing, Chiangmai University 5.62.158.117] at [07/18/16]. Copyright © McGraw-Hill Global Education Holdings, LLC. Not to be redistributed or modified in any way without permission.
administering more than half his fluid volume in the first hour, the nurse should
be observant for which of the following complications?
+
A. K = 2.5 mEq/L
++
B. Ca = 12 mEq/L
C. Platelet count of 250,000 cm 3
D. pH 7.20, pCO 45, HCO 10
2 3
3. A patient is admitted to the hospital in Class III hemorrhage. The nurse is aware
that the patient will exhibit which of the following signs/symptoms in this stage
of hemorrhagic shock?
A. Heart rate of 100
B. Bradypnea
C. Drop in MAP of less than 60
D. 30% to 40% blood loss

4. A patient is admitted to the ICU post surgical wiring of a Le Fort III facial fracture.
Which of the following would be contraindicated in this patient’s nursing care?
A. Insertion of a nasogastric tube for nausea
B. Administration of a simple mask
C. Monitoring the site for redness, irritation, and exudate
D. Assessing the surgical site for symmetry