A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

Measure the client's abdominal girth.

Monitor the client's recent hemoglobin levels.

Prepare for nasogastric tube (NGT) insertion.

Notify the healthcare provider (HCP) of the client's status.

Answer and Explanation

The Correct Answer is D

A. Measure the client's abdominal girth. While tracking abdominal distension is useful, it does not address the underlying cause of the client's deterioration. Measuring girth should not delay immediate intervention for a potentially life-threatening condition.
B. Monitor the client's recent hemoglobin levels. A drop in hemoglobin would indicate internal bleeding, but waiting for lab results could delay necessary treatment. The client is already showing signs of early shock, requiring urgent medical intervention rather than just monitoring.
C. Prepare for nasogastric tube (NGT) insertion. An NGT may be needed for bowel obstruction or paralytic ileus, but the client's worsening condition suggests a more urgent issue, such as intra-abdominal hemorrhage. Addressing the potential bleeding takes priority over decompression.
D. Notify the healthcare provider (HCP) of the client's status. The client's tachycardia, tachypnea, cool pale skin, and worsening abdominal distension suggest early shock, likely due to postoperative internal bleeding or abdominal compartment syndrome. Immediate notification of the HCP ensures rapid assessment, diagnostic testing, and potential emergency intervention to prevent further deterioration.

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Correct Answer is C

Explanation

A. Suture removal kit. A suture removal kit is used when the chest tube is ready for removal, but it is not necessary to keep at the bedside during routine chest tube management. The priority is ensuring emergency supplies are available if the tube becomes dislodged.
B. Suction catheter. A suction catheter is used to remove secretions from the airway but is not essential for managing a chest tube. Chest drainage systems function independently to remove air or fluid, and routine suctioning is not required for chest tube management.
C. Sterile gauze dressing. If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
D. Sterile piston syringe. A sterile piston syringe is used for irrigating wounds or suctioning secretions, but it is not necessary for chest tube management. The closed drainage system should never be manually flushed unless specifically ordered by a healthcare provider.

A. Hyperglycemia. B. Hypotension. C. Paralytic ileus and abdominal distention. D. Muscle twitching and digit numbness.

Correct Answer is D

Explanation

A. Hyperglycemia. While elevated blood glucose can occur in acute pancreatitis due to pancreatic inflammation impairing insulin secretion, it is not an electrolyte imbalance. The question specifically asks about electrolyte-related manifestations.
B. Hypotension. Hypotension in acute pancreatitis is often due to fluid shifts (third-spacing) and systemic inflammation, rather than a direct electrolyte imbalance. Though dehydration and electrolyte losses can contribute to hypotension, this is not the most specific sign of an electrolyte disturbance.
C. Paralytic ileus and abdominal distention. Hypokalemia can lead to paralytic ileus, but ileus and distention are also caused by peritoneal irritation, inflammation, and impaired motility due to pancreatitis itself. While potassium imbalance could contribute, this is not the most direct electrolyte-related symptom.
D. Muscle twitching and digit numbness. Hypocalcemia is a common electrolyte imbalance in acute pancreatitis, caused by fatty acid breakdown binding calcium, leading to saponification. This results in neuromuscular excitability, causing muscle twitching, paresthesia (numbness/tingling), and positive Chvostek’s or Trousseau’s signs. These symptoms are clear indicators of an electrolyte disturbance related to pancreatitis.

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A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

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Naxlex Comprehensive Predictor Exams

A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?

Correct Answer is C

Explanation

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse has received the arterial blood gas (ABG) results. Drag one condition and one client finding to complete the sentence(s). Based on the ABG values, the nurse knows that the client has dropdownrelated todropdown

The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO2) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse implement?

A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

A postoperative client is admitted to the intensive care unit (ICU) with an inflated pressure infuser containing a solution of heparin 2 units/ml attached to an intra-arterial (IA) cannula. Which finding indicates that the heparin infusion has achieved its therapeutic use?

Exhibits Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.