A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immédiately to the provider?Select all that apply.
Urine output
Heart rate
Sodium level
Respiratory status
Pain
Serum amylase level
Mental confusion
Blood pressure
Temperature
Cold, clammy skin
Correct Answer : B,D,G,H,J
Rationale for Correct Options:
- Heart rate. The heart rate has increased from 90/min on Day 1 to 132/min on Day 2. This significant elevation is concerning for worsening systemic inflammation, hypovolemia, or sepsis and requires immediate intervention.
- Respiratory status. The client initially had diminished breath sounds at the lung bases, but by Day 2, breath sounds are diminished throughout. This suggests worsening respiratory function, possibly due to acute respiratory distress syndrome (ARDS) or pleural effusion, both of which can complicate severe pancreatitis. Immediate assessment and intervention are necessary.
- Mental confusion. The client was alert and oriented on Day 1 but is now disoriented to person, place, and time on Day 2. This change in mental status can indicate worsening systemic inflammation, sepsis, hypoxia, or metabolic disturbances such as hypocalcemia. Immediate evaluation is needed.
- Blood pressure. While the client’s initial blood pressure was stable at 126/78 mm Hg, the current reading is not provided. If the client is experiencing hypotension, it could indicate worsening shock, requiring urgent intervention.
- Temperature. The client’s temperature increased from 37.2 °C (99 °F) on Day 1 to 38.9 °C (102 °F) on Day 2. This suggests a developing infection, such as infected pancreatic necrosis or sepsis, which requires immediate reporting and further evaluation.
- Cold, clammy skin. Cold, clammy skin is a sign of poor perfusion, which may indicate impending shock due to worsening sepsis or hypovolemia. This is an urgent finding requiring immediate attention.
Rationale for Incorrect Options:
- Urine output. The client’s urine output was documented as 60 mL/hr, which is within the normal range. There is no indication of oliguria or anuria that would require immediate reporting.
- Sodium level. The sodium level of 142 mEq/L is within the normal range and does not indicate a critical electrolyte imbalance requiring urgent intervention.
- Pain. The client’s pain has increased from 8/10 to 10/10 despite receiving morphine via a PCA pump. While pain management is crucial, worsening pain alone is not the most urgent concern compared to systemic complications like respiratory failure or hemodynamic instability.
- Serum amylase level. Although the serum amylase level is significantly elevated at 498 units/L, this is expected in acute pancreatitis and does not necessarily indicate an immediate life-threatening emergency. Trends in amylase and lipase levels are important for monitoring, but they do not require urgent reporting unless accompanied by other signs of deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Anticipate that the insulin glargine will peak in 3 hours." Insulin glargine is a long-acting basal insulin with no pronounced peak. Instead, it provides a steady level of insulin over 24 hours, reducing the risk of hypoglycemia. Unlike short- or intermediate-acting insulins, it does not have a defined peak time.
B. "Draw up the insulin lispro and insulin glargine in separate syringes." Insulin glargine should never be mixed with other insulins in the same syringe, as it has a unique pH that can cause precipitation when combined. Insulin lispro, a rapid-acting insulin, can be mixed with some other insulins, but it must be drawn up separately from insulin glargine to maintain its stability and effectiveness.
C. "Expect insulin glargine to be cloudy." Insulin glargine is a clear solution. Cloudy insulins, such as NPH (neutral protamine Hagedorn), require gentle rolling before administration to mix the suspension evenly. If insulin glargine appears cloudy, it may be contaminated or compromised and should not be used.
D. "Take an extra dose of insulin lispro prior to aerobic exercise." Taking extra insulin lispro before exercise can increase the risk of hypoglycemia, as physical activity naturally lowers blood glucose levels. Clients with diabetes should monitor their blood glucose before, during, and after exercise and may need to adjust their carbohydrate intake rather than taking additional insulin.
Correct Answer is C
Explanation
A. "I should eat a high-fat diet for several weeks." After a laparoscopic cholecystectomy, clients are typically advised to follow a low-fat diet for several weeks to help their bodies adjust to the absence of the gallbladder. The gallbladder stores bile, which aids in the digestion of fats. Without it, a high-fat diet can lead to gastrointestinal discomfort, including cramping and diarrhea. Gradually reintroducing fats based on tolerance is recommended.
B. "I should expect to have diarrhea until my diet changes." While some clients may experience temporary diarrhea after surgery, it is not a universal side effect. Changes in bowel habits can occur due to alterations in bile flow, but not all clients will have diarrhea. Maintaining a balanced diet and gradually increasing fiber intake can help regulate bowel movements and minimize gastrointestinal disturbances.
C. "I should leave my steri-strips on until they fall off." Steri-strips, or adhesive strips used to secure the incision, should be left in place until they naturally fall off, which usually occurs within one to two weeks. Removing them prematurely can compromise the healing process and increase the risk of infection or wound dehiscence.
D. "I should expect to have nausea for several days." Nausea can occur after surgery due to anesthesia, but it should not persist for several days. While some postoperative nausea is normal, ongoing or severe nausea may indicate a complication, such as an adverse reaction to medication or an underlying issue, and should be communicated to the healthcare provider for further evaluation and management.
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