A nurse is assessing a client who has endometritis. Which of the following findings should the nurse expect?

Rationale:

A. Document assessment findings and interventions after providing care for a group of clients: Delaying documentation can lead to inaccuracies or omissions due to forgetfulness. Real-time or immediate documentation ensures completeness and supports continuity of care.

B. Gather supplies for a client's dressing change after removing the old dressing: Supplies should be gathered in advance to minimize delays and reduce the risk of contamination or client exposure. Doing so afterward is inefficient and interrupts workflow.

C. Complete activities for one client before moving to the next client: Focusing on one client at a time improves efficiency, reduces errors, and supports prioritization. It allows for full attention on care tasks and appropriate time management across the shift.

D. Delay cleaning personal work area until the end of the shift: Maintaining a clean and organized workspace throughout the shift helps prevent errors, improves efficiency, and supports infection control, especially in high-traffic care areas.

Rationale for Correct Choices:

• Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
• Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

• Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
• Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
• Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
• Blood glucose level: Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.