Situation 1: The nurse at the emergency department is working a busy night shift at a downtown

hospital. The nurse is assigned to a female client involved in a motor vehicle accident. Below are the
patient’s assessments obtained by the nurse:
Neurological Decreased level of consciousness noted. Oriented to person, place and time.
Gastrointestinal 8 cm open laceration noted at left upper quadrant. Left abdominal pain reported
as 8/10. Abdomen is tender and distended. Diminished bowel sounds x4.
Cardiovascular Skin is cool and clammy upon touch. Rapid S1 and S2 sounds. Capillary refill time
is 4 seconds. Radial and dorsal pedal pulse are 1+ and thready bilaterally.
Vital Signs P: 131 bpm; RR: 27 cpm; BP: 91/63 mmHg; Temp: 36.5 deg. C or 97.7 deg. F
O2 saturation level: 85% on room air
Respiratory Respirations are shallow and labored. No adventitious sounds heard upon
auscultation.
Integumentary 8 cm open laceration noted on left upper quadrant. Continuous blood loss noted;
dressing that was applied 1 hour go by EMT is saturated with fresh blood.

Laboratory results:
Lab Test Result Reference Rating
Hemoglobin 6.7 g/dL (67 g/L) 12-16 g/dL (120-160 g/L)
Hematocrit 25% 37%-47%

1. Which of the following assessments require immediate follow-up? Select all that apply. (5 points)
a. Pain level
b. Capillary refill time
c. Abdominal laceration
d. Peripheral pulses
e. Respirations
f. Bowel sounds
g. Temperature
h. Laboratory results
i. Level of consciousness
2. For each category, indicate what findings would be expected for the two types of shock. (8 points)
a. Hypovolemic
i. Hypotension
ii. Tachycardia
iii. Warm, dry extremities
iv. Irregular pulses
v. Hypothermia
b. Neurogenic (with no Increased ICP involved)
i. Hypotension
ii. Tachycardia
iii. Warm, dry extremities
iv. Irregular pulses
v. Hypothermia
3. The physician in the Emergency Department diagnosed the client with hypovolemic shock.
Complete the following sentence by choosing from the list of options.
The nurse should first _____ followed by_______. (2 points)
a. Administer pain medication – change abdominal dressing
b. Change abdominal dressing – administer pain medication
c. Administer oxygen – establish intravenous access
d. Establish intravenous access – administer pain medication
 4. Which of the following nursing interventions are anticipated for the care of the client? Select all
that apply. (4 points)
a. Initiate precautions for autonomic dysreflexia
b. Draw blood for type and screen
c. Obtain abdominal CT scan
d. Insert an indwelling urinary catheter
e. Perform fluid resuscitation using 0.45% NaCl
f. Obtain 12-lead electrocardiogram
5. The nurse assesses the client 10 minutes after initiating the blood transfusion. The nurse notes
that the client is exhibiting local erythema and hives to the upper limbs. The client reports of
pruritus that began 10 minutes after infusion of blood. Which of the following actions should the
nurse carry out? Select all that apply. (4 points)
a. Administer antihistamines
b. Stop the infusion
c. Notify the blood bank
d. Notify the healthcare provider
e. Administer antipyretics
f. Obtain blood cultures
g. Initiate cardiopulmonary resuscitation
6. The spleen is the most vascular organ, as it is responsible for filtering the blood in the body.
Injuries to the spleen can cause significant bleeding in the peritoneum, causing hypovolemia and
shock. Clients with splenic injury will require blood transfusions and crystalloids as initial therapy
for fluid resuscitation. The client in this situation was immediately transferred to the operating
room and underwent an open partial splenectomy surgery. Which of the following findings
indicate that the client is recovering as expected following surgery?
a. Left shoulder pain rated as 2/10 and dull
b. Standing blood pressure of 85/56 mmHg
c. Dressing saturated with sanguineous drainage
d. Urine output of 825 mL per day?

Situation 2: The nurse arrives to her evening shift at a busy emergency department. The nurse is
assessing a 55-year-old client complaining of shortness of breath and a swelling abdomen. Admission
assessment of patient appears below:
Date of Admission: 12/12/20XX
Chief Complaint: “Swelling abdomen,” ascites, shortness of breath
Pre-existing Conditions: Hepatitis C, diagnosed 15 years ago.
Medications: Client states he was on prescribed direct-acting antivirals when first diagnosed with
HepC, but stopped taking meds due to side effects.
Do you smoke? Yes (Two packs a week)
Do you consume alcohol? Yes (5 to 8 beers a week)
Do you use drugs? No
Vital signs:
Heart rate: 90 bpm Temperature: 37.7 deg. C (99.9 deg. F)
Respiratory rate: 17 cpm SpO2: 97% on RA
Blood pressure 128/87 mmHg
Lab Findings:
Sodium: 130 mmol/L ALT: 60 units/L
Potassium: 3.3 mmol/L AST: 70 units/L
Albumin: 2.4 g/dL Bilirubin: 13.5 mg/dL
Ammonia: 167 mg/dL
7. Which of the following lab findings for the client are below normal range? (Dx-1 point)
a. Ammonia e. ALT
b. Bilirubin f. AST
c. Albumin g. Potassium
d. Sodium
8. During the head-to-toe assessment, the nurse finds may manifestations of cirrhosis. Match the
assessment findings with the laboratory abnormality that best explains it:
a. Ascites and edema
i. Decreased serum albumin
ii. Increased ammonia
iii. Increased INR and PT
iv. Increased bilirubin
b. Bruising
i. Decreased serum albumin
ii. Increased ammonia
iii. Increased INR and PT
iv. Increased bilirubin
c. Asterixis and lethargy
i. Decreased serum albumin
ii. Increased ammonia
iii. Increased INR and PT
iv. Increased bilirubin

d. Jaundice, pruritus, clay-colored stools

i. Decreased serum albumin
ii. Increased ammonia
iii. Increased INR and PT
iv. Increased bilirubin
9. What is most likely causing the client to experience ascites?
a. Enlarged liver size
b. Portal hypertension
c. Impaired coagulation
d. Urinary retention
10. Common complications of cirrhosis include portal hypertension, ascites, esophageal varices,
Hepatorenal Syndrome, Hepatic Encephalopathy and Spontaneous Bacterial Peritonitis. Which of
the following actions should be avoided by the patient? Select all that apply. (4 points)
a. Vomiting
b. Lying with HOB flat
c. Forceful coughing
d. Drinking alcohol
e. Straining
11. An hour after admission, the client anxiously calls the nurse to report a new onset hematemesis
and feeling faint. Emesis in the basin reveals large amount of bright red blood. The nurse
immediately obtains new set of vital signs:
Heart rate: 120 bpm Temp: 37.7 deg C (99.9 deg F)
BP: 90/65 mmHg SpO2: 92%
The nurse contacts the health care provider. Select four (4) other interventions that are
appropriate for the nurse to perform. (4 points)
a. Prepare to administer vasodilators
 b. Monitor for orthostatic hypotension
c. Administer 2L oxygen via nasal cannula
d. Prepare for possible blood transfusion
e. Maintain NPO status
f. Teach client to perform vasovagal responses
12. Once the client was stabilized, he underwent an endoscopic variceal ligation procedure and was
transferred to a surgical step-down unit for observation. Which of the following signs may
indicate re-bleeding of esophageal varices has occurred?
a. Increase in temperature
b. Sudden hypertension
c. Palmer erythema
d. Melena stools
13. Portal hypertension may complicate to abdominal compartment syndrome, which is
characterized by multiple organ dysfunction. With abdominal compartment syndrome, the
abdominal pressure is:
a. Greater than 20 mmHg c. Less than 15 mmHg
b. Greater than 50 mmHg d. Less than 20 mmHg
14. This occurs when a disease or disorder inside the abdomen is directly responsible for
compartment syndrome.
a. Primary or acute abdominal compartment syndrome
b. Secondary abdominal compartment syndrome
c. Chronic abdominal compartment syndrome
d. Intra-abdominal hypertension
15. This condition occurs when no visible intra-abdominal injury is present but injuries outside the
abdomen cause fluid accumulation in the abdomen, which may lead to sepsis.
a. Primary or acute abdominal compartment syndrome
b. Secondary abdominal compartment syndrome
c. Chronic abdominal compartment syndrome
d. Intra-abdominal hypertension
16. This condition occurs in the presence of cirrhosis and ascites or related disease states, often in
the later stages of the disease.
a. Primary or acute abdominal compartment syndrome
b. Secondary abdominal compartment syndrome
c. Chronic abdominal compartment syndrome
d. Intra-abdominal hypertension
17. Which of the following indicate that the patient has progressed to developing abdominal
compartment syndrome? Select all that apply (5 points)
a. Increased abdominal girth
b. Increased tube feeding residuals
c. Decreased bowel sounds
d. Difficulty of breathing
e. Decreased urine output
f. Bradycardia
18. The nurse anticipates that the patient will have to undergo which diagnostic procedure to
ascertain abdominal compartment syndrome?
a. Computed tomography scan c. X-ray
b. Positron emission tomography scan d. Abdominal UTZ
19. Which of the following nursing interventions are appropriate for a client with impending
abdominal compartment syndrome? Select all that apply (4 points)
a. Elevate HOB by 20 degrees
 b. Nasogastric and rectal tube insertion
c. Discontinue enteral nutrition
d. Prepare patient for decompressive laparotomy
e. Log roll patient every 2 hours, including placing patient in prone position
20. The nurse knows that delay in abdominal decompression in the management of abdominal
compartment syndrome may lead to:
a. Hypovolemic shock c. Ischemia
b. Neurogenic shock d. Coagulopathy