A nurse in an urgent care facility is caring for a client.

Exhibits

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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["B","C","E","F"]

Explanation

A. Hemoglobin: Although an improvement in hemoglobin would be ideal, it may take more time to see a significant change after blood loss or transfusion. A rise in hemoglobin indicates that the body is recovering from blood loss, but it is not as immediate an indicator of improvement as other factors, such as heart rate or blood pressure stabilization.

B. Heart rate: A decrease in the heart rate toward the normal range (60-100 beats/min) indicates improvement in the client's condition. The initial heart rate of 120-128 beats/min (tachycardia) suggests the client may have been compensating for blood loss or pain. A more stable heart rate would suggest a response to treatment and improvement in their cardiovascular status.

C. Pain level: A reduction in pain score is an important indicator of recovery post-surgery. After an emergency cesarean birth, pain management is a critical aspect of recovery, and a reduction in pain intensity would suggest that the client is improving and responding well to pain management interventions.

D. Temperature: A normal temperature would suggest no infection or complications. However, temperature changes in the immediate postpartum period can be influenced by various factors (e.g., infection, hormonal changes, or recovery from surgery). It is not as immediate an indicator of recovery as heart rate or blood pressure.

E. Vaginal bleeding: A decrease in vaginal bleeding, especially after a cesarean, would indicate that bleeding is being effectively controlled and the uterus is contracting appropriately, reducing the risk of hemorrhage or complications like uterine atony.

F. Blood pressure: A return to normal blood pressure levels (e.g., closer to the pre-pregnancy baseline) would indicate that the client's circulatory status is stabilizing. The dropping blood pressure seen earlier (from 95/62 mm Hg to 85/48 mm Hg) indicated hypovolemic shock or a response to blood loss, so stabilization and an increase in blood pressure would be a positive sign.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

The client has dark red vaginal bleeding and low hemoglobin (8.1 g/dL) and hematocrit (24%), which indicate significant blood loss.

The low blood pressure (95/62 mm Hg) and tachycardia (104 bpm) are signs of the body's response to blood loss, which can lead to hypovolemic shock.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits The nurse is caring for a client on the postpartum unit. The nurse is caring for the client following an emergency cesarean birth. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["B","C","E","F"]

Explanation

A nurse is caring for a client. Exhibits Complete the following sentence by using the lists of options. The client is at risk of developing ____1__ due to the client ___2___.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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