A 45-year-old female patient is admitted to the emergency department with severe abdominal pain, fever, and nausea. She reports that the pain started suddenly and has progressively worsened. The healthcare provider suspects peritonitis and orders immediate interventions.
Physical examination
On examination, the patient has a distended abdomen, guarding, and rebound tenderness.
Her vital signs are as follows:
Temperature 102.4°F (39.1°C), Heart rate 120 bpm, Blood pressure 90/60 mmHg, and Respiratory rate 24 breaths per minute.
Which of the following complications is the nurse's highest priority to monitor for in this patient?
Intestinal obstruction
Hypovolemic shock
Electrolyte imbalance
Sepsis
The Correct Answer is B
A. Intestinal obstruction: While peritonitis can lead to intestinal obstruction, it is not the most immediate life-threatening complication compared to hypovolemic shock or sepsis.
B. Hypovolemic shock: This is a critical condition that can occur due to severe fluid loss, which might be a concern in peritonitis due to fluid shifts into the abdominal cavity. However, the patient’s signs of systemic infection (fever, elevated heart rate, low blood pressure) suggest that sepsis is a more imminent threat.
C. Electrolyte imbalance: Electrolyte imbalances are possible due to fluid loss, but they would be secondary to the more urgent concern of hypovolemic shock.
D. Sepsis: Sepsis is the highest priority due to the patient’s vital signs and symptoms indicating a systemic infection. Early recognition and treatment of sepsis are crucial to prevent organ failure and other severe complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Crohn's disease causes continuous inflammation of the mucosa and sub-mucosa of the colon and rectal linings: This description is more applicable to ulcerative colitis, which involves continuous inflammation and primarily affects the colon and rectum, not Crohn's disease, which can affect any part of the GI tract.
B. Crohn's disease is characterized by a transmural granulomatous inflammation that can affect any part of the gastrointestinal tract: While this is an accurate medical description of Crohn’s disease, it uses technical language that may be difficult for a patient to understand.
C. Crohn's disease has the appearance of a patchwork quilt with some areas that are clear and some with sores. This description provides a clear and visual explanation of the nature of Crohn’s disease, which typically affects the gastrointestinal tract in a "skip lesion" pattern, where some areas are inflamed (sores), and others appear normal (clear areas).
D. Crohn's disease looks like what would appear to be a second-degree burn in the colon and rectum areas only: This description is inaccurate for Crohn’s disease, as it implies the disease is limited to the colon and rectum, which is not the case. Crohn’s can affect any part of the gastrointestinal tract from the mouth to the anus.
Correct Answer is ["A","B","C","D"]
Explanation
A. Administer IV fluids: The patient is hypotensive (blood pressure 88/54 mmHg) and tachycardic (heart rate 115 bpm), indicating possible hypovolemic shock due to blood loss. Administering IV fluids will help to stabilize blood pressure.
B. Prepare for possible blood transfusion: The patient's hemoglobin level is critically low (6.5 g/dL), indicating significant blood loss and severe anemia. Preparing for a blood transfusion is crucial to correct the anemia.
C. Monitor hemoglobin and hematocrit levels: Continuous monitoring of hemoglobin and hematocrit levels is vital to assess the severity of the patient's anemia and response to treatment, guiding further interventions.
D. Administer a proton pump inhibitor (PPI): PPIs can help reduce gastric acid secretion, which may help control bleeding from peptic ulcers, a common cause of upper GI bleeding.
E. Administer oral iron supplements to address anemia: Oral iron supplements are typically used for long-term management of iron deficiency anemia but are not effective for immediate correction of severe anemia, particularly in an acute setting with ongoing blood loss.
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