A. Decreased blood urea nitrogen (BUN): BUN typically increases with dehydration.

B. Increased hematocrit: Hemoconcentration occurs in dehydration, increasing hematocrit levels.

C. Decreased urine specific gravity: Dehydration typically causes an increase in urine specific gravity.

D. Increased calcium level: Calcium levels do not directly indicate fluid volume status.

A. Insert the NG tube is the correct choice because the provider's order specifically states to "insert NG tube to low-intermittent suction." This intervention is a key part of managing acute pancreatitis, especially in clients experiencing nausea, vomiting, and abdominal distention.

B. Decompress the stomach and reduce vomiting is the correct reason because an NG tube helps remove gastric contents, reducing the stimulation of pancreatic enzyme secretion, which worsens inflammation. It also alleviates symptoms of nausea and vomiting, helping prevent further fluid loss and electrolyte imbalances.

Incorrect answers:

B. Administer prescribed antibiotics: There is no mention of an order for antibiotics in the provider’s prescriptions.

C. Perform abdominal assessment: While an abdominal assessment is always part of nursing care, it is not the primary action to implement the provider’s prescription. The nurse should still monitor for worsening symptoms, such as peritoneal signs or increasing distention.

A. "I should apply clean dressings over the top of blood-saturated dressings and hold pressure.” This prevents disruption of clot formation and controls bleeding.

B. "I can clean wounds with hydrogen peroxide.” Hydrogen peroxide can damage healthy tissue and delay healing.

C. "I can carefully remove the object from a penetrating wound.” Objects should be left in place until medical professionals remove them.

D. "I should place the affected area in a dependent position.” Elevating an injured limb helps reduce swelling and bleeding.

Apply firm, direct pressure to the catheter insertion site is the best first action because it directly addresses the immediate concern of bleeding, helping to prevent excessive blood loss and stabilize the client.

Assess vital signs and assess for signs of hypovolemia is the best next action, as the client's increasing heart rate and decreasing blood pressure suggest potential blood loss, which could lead to hypovolemic shock.

Incorrect answers;

i

Lowering the head of the bed and assessing circulation (B in i) is important but should follow bleeding control.

Increasing IV fluids (C in i) may be necessary but should be done based on provider orders after controlling bleeding.

ii

Preparing for fluid resuscitation (B in ii) is relevant but is not the first step; monitoring vitals is a more immediate priority.

Notifying the provider (C in ii) is crucial but should occur after assessing the client's status to provide accurate information.

A. Orange slices: Orange slices should be avoided because they contain a fibrous membrane that can be difficult to chew and swallow, posing a choking risk. Additionally, the acidic nature of oranges may cause irritation in some clients.

B. Ground hamburger: Appropriate for a mechanical soft diet because it is easy to chew and swallow.

C. Cooked green beans: Softened through cooking, making them easy to chew.

D. Canned peaches: Soft and easy to chew, making them suitable for this diet.

A. Dry skin: More commonly associated with dehydration or skin conditions, not a direct response to stress.

B. Increased urinary output: Stress usually triggers the release of antidiuretic hormone (ADH), leading to decreased urinary output rather than an increase.

C. Dilated pupils: Stress activates the sympathetic nervous system (fight-or-flight response), leading to pupil dilation to enhance vision in a perceived emergency.

D. Hyperactive bowel sounds: Stress can affect digestion, but it is more commonly associated with nausea, not necessarily hyperactive bowel sounds.

Oxygen Saturation: 84% on 3L nasal cannula

• The client’s oxygen saturation has dropped from 89% to 84%, indicating worsening hypoxia. In an asthma exacerbation, declining oxygen levels suggest inadequate gas exchange and potential progression to respiratory failure.

Mucous Membranes Cyanotic

• Cyanosis is a late sign of hypoxia and indicates that the client is not oxygenating adequately. This suggests that bronchoconstriction and airway obstruction are worsening despite initial treatment.

Respiratory Rate: 27/min (Increased from 22/min)

• An increasing respiratory rate suggests increased work of breathing. The client is attempting to compensate for worsening airway obstruction, which can lead to respiratory fatigue if not managed promptly.

Client Appears Anxious

• Anxiety in this context may indicate air hunger and respiratory distress. Clients in worsening asthma exacerbations often become restless or agitated due to inadequate oxygenation.

When analyzing cues, the nurse should identify HCTZ, QD, QOD .1 mg, and >180mg systolic as error-prone abbreviations. Medications names, such as hydrochlorothiazide, should be spelled out. QD should be written as daily and QOD should be written as every other day. Decimal points should be written using a leading zero and greater than and less than should be written out rather than using symbols.

A. Mix the medications together and administer through the NG tube. Incorrect because medications should be given separately to prevent drug interactions and ensure each is fully delivered.

B. Crush the sublingual medication into powder form. Incorrect because sublingual medications are designed to be absorbed through the oral mucosa, not the gastrointestinal tract. Crushing them negates their intended action.

C. Dissolve crushed tablet medications in sterile water. Sterile water is preferred for dissolving medications because it reduces the risk of bacterial contamination and prevents potential drug interactions that may occur with other fluids.

D. Flush the tube with 5 mL saline between each medication. Incorrect because a minimum of 15-30 mL of water is recommended between medications to prevent tube blockage.

A. A stand assist lift: A stand assist lift is appropriate for clients who can bear some weight and have upper body strength. It provides support during the transfer while allowing the client to participate in the movement, promoting mobility and independence.

B. A footboard: A footboard is used to prevent foot drop in bedridden clients and is not a transfer device. It does not assist with movement from a chair to a bed.

C. A slide board: A slide board is typically used for clients who have good upper body strength but cannot bear weight on their legs, such as paraplegic clients. Since this client can bear partial weight, a slide board is not the best option.

D. A mechanical lift with a full-body sling: A full-body sling mechanical lift is used for clients who cannot bear weight and have minimal or no upper body strength. Since this client can bear some weight and has upper body strength, a stand assist lift is the more appropriate choice.