critical care hesi practice evolve The triage nurse is assessing a victim of a stab wound. According to the paramedics, the
victim was stabbed by a male
... [Show More] 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? (Select all that apply.)
A. Heart. Correct
B. Lungs. Correct
C. Stomach.
D. Intestines.
E. Diaphragm. Correct
Stab wounds are low velocity wounds that the path of injury to the underlying organs is
determined by the direction of the path of the impaled knife and the length and width of the
blade. The gender of the attacker is important to know because females tend to stab in a
downward direction (trajectory) and males tend to stab in an upward direction (trajectory).
Awarded 0.99 points out of 0.99 possible points.
2. 2.ID: 20120683612
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?
A. Metabolic panel with electrolytes.
B. Complete blood count.
C. Liver function test.
D. Blood culture. Correct
The client is demonstrating clinical signs and symptoms of infective endocarditis. The key
in treating infective endocarditis is identifying the causative infectious agent and treat with
the appropriate antibiotics. Blood cultures should identify which bacteria is the offending
bacteria causing the endocarditis. What distinguishes infective endocarditis from the other
conditions listed is the presence of the heart failure symptoms of edema, and S3 and S4 heart
sounds.
Awarded 1.0 points out of 1.0 possible points.
3. 3.ID: 20120683610
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 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. [Show Less]