Continue to consider the trauma patient from the previous question: A trauma patient is brought into the ED via ambulance following a motorcycle vs SUV collision.  On first look, the nurse sees the patient is bloody in several areas with “road rash” and gravel still adhering to the skin. He appears to be bleeding from scratches to the neck and face. He is on a backboard with C-spine immobilization and is breathing spontaneously with a simple oxygen mask in place. His respiratory pattern and rate is unorganized. His BP is 152/31, HR 41. His eyes remain closed to speech, open to touch. PERRLA. He is moving his extremities X 4 restlessly on the backboard/gurney. No abdominal injuries are externally noted. Abdomen feels distended and firm to touch. No bowel sounds are detected.    The RN further assesses the patient’s belly and, in addition to the previous findings, also notes a bluish discoloration around the umbilicus. The RN recognizes:  

Which of these statements is accurate about the AHA’s Time-Driven Stroke Algorithm?

An RN is caring for an actively dying patient in a cardiac step-down unit who is not intubated and has just become a DNR earlier today. The patient appears restless and in pain, although not fully responsive at this time.  As the RN approaches the bedside with the ordered dose of IV push morphine, he/she is aware the patient may experience respiratory depression or even respiratory arrest after administration. Several tearful family members are at the bedside. They state they are glad the nurse is there to give medication because they hate to see their loved one looking so uncomfortable! They are praising the efforts of the health care team for taking such good care of their family member.    When considering both the needs of the patient and family members, which actions are recommended in this situation? 

The monitor tech asks you to check on a patient who’s ECG alarms are dinging. This is the rhythm on the monitor (assume this is a 6 sec strip): It is night shift and as you enter the room, you see the patient in bed with eyes closed and apparently asleep. What should be the nurse’s next action? 

Please enjoy this HIV/AIDS matching question 🙂   Options are used only once or not at all.

You are caring for a victim of a sexual assault who has just been brought into the ED by a roommate by private auto.  The victim has been quiet and it has been difficult to get all the details of the events surrounding her injuries. You suspect she is having a dissociative response and that tonic immobility may have played a role in the events. The nurse is aware that:

Still thinking of the patient from the previous question: A 44 year old patient is admitted with fever and altered LOC.  Her blood pressure on admission is 74/30.  The patient is tachycardic and tachypneic and has a history of pneumonia for one week at the long-term care facility.. Temp 102.1 F, HR 114, RR 24. The patient has been started of the “Sepsis Care Bundle” using a standardized order set that follows best practices for care of sepsis and septic shock patients.  The RN anticipates which lab value to be typically followed, with repeated lab draws, while using the Sepsis Care Bundle flow sheet? Why is this lab important?

Patients in liver failure often have prolonged PT  (prothrombin) times on their lab profiles.  What is the most likely pathophysiologic cause of this abnormal lab finding?

The RN is working with the trauma team in the ED to perform the Primary Trauma Assessment on a patient just brought in by paramedics after a multiple car MVA.    As the RN moves to letter E of the assessment, what should be considered? (indicate you are familiar with letter “E” in the ABCDE mnemonic)

A patient is complaining of chest pain and suddenly goes into the following dysrhythmia. His eyes are closed and he is groaning on the bed. When you shake him and ask him if he is okay, he only makes groaning sounds, no intelligible speech. You call rapid response and they have arrived with a team and crash cart. What treatment do you anticipate?