A nurse in an urgent care facility is caring for a client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition: Pancreatitis
Rationale:
The client's presentation with severe upper left quadrant abdominal pain, nausea, febrile status, tachypnea, and increased amylase and lipase levels suggests pancreatitis. Pancreatitis commonly presents with abdominal pain, nausea, and vomiting (though vomiting is not reported here), and elevated pancreatic enzymes (amylase and lipase). The elevated glucose level (200 mg/dL) may also point to pancreatitis since the pancreas plays a role in glucose metabolism.
Actions to Take:
Administer opioids for pain:
Rationale: Pain management is crucial in pancreatitis. Administering opioids like morphine or hydromorphone can help manage the severe pain, improving comfort and reducing distress.
Maintain separate equipment for the client:
Rationale: In cases of pancreatitis, particularly if caused by an infectious etiology, it is essential to avoid cross-contamination. Separate equipment reduces the risk of spreading infections if relevant.
Parameters to Monitor:
Dyspnea:
Rationale: The patient is tachypneic, and it's important to monitor for any progression of respiratory issues. Dyspnea could indicate worsening respiratory status or complications such as pleural effusion.
Hypotension:
Rationale: Hypotension can be a sign of shock, a potential complication of pancreatitis due to fluid loss, or systemic inflammatory response. It is important to monitor for signs of hypotension to ensure adequate perfusion and prevent shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Levothyroxine is usually administered in the morning and is prescribed correctly here.
B. The prescribed dose of Digoxin 250 mcg is unusually high for a daily dose. Typically, digoxin is prescribed in lower doses, and the nurse should clarify this prescription with the provider to ensure it is correct.
C. Ceftriaxone is correctly prescribed as an IV antibiotic with a standard interval.
D. Acetaminophen is correctly prescribed as a dosage of 650 mg every 6 hours.
Correct Answer is B
Explanation
A. Sinus tachycardia: Incorrect. Sinus tachycardia shows a regular rhythm with identifiable P waves, not a wavy baseline.
B. Atrial fibrillation: The wavy baseline and absent P waves are characteristic of atrial fibrillation, a common arrhythmia that results from rapid and irregular electrical activity in the atria.
C. Second-degree heart block: Incorrect. Second-degree heart block would show P waves with intermittent conduction of the QRS complex, not a wavy baseline.
D. Ventricular asystole: Incorrect. Ventricular asystole would show no electrical activity, which is different from a wavy baseline.
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