A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immediately to the provider?
Select all that apply.
Blood pressure
Mental confusion
Cold, clammy skin
Sodium level
Pain
Heart Rate
Serum amylase level
Respiratory status
Urine output
Temperature
Correct Answer : A,B,C,F,G,I,J
A. The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.
B. The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.
C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.
D. The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.
E. While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.
F. The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.
G. The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.
H. The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.
I. The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.
J. The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.
These findings indicate that the client may have severe acute pancreatitis, which can lead to systemic complications such as hypovolemia, shock, hypocalcemia, respiratory failure, and multiorgan failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is D.
Crohn's disease is a chronic inflammatory bowel disease that causes swelling and inflammation in the digestive tract. It can cause abdominal pain, diarrhea, weight loss, and malnutrition. There is no cure for Crohn's disease, but treatments can reduce inflammation and symptoms, and sometimes bring about long-term remission, which means a period of time when symptoms are absent or mild.
Correct Answer is ["A","C","D"]
Explanation
The correct answer is Choices A, C, and D.
Choice A rationale:
The statement, "I should avoid douching or using tampons for 24 hours after the Pap smear," demonstrates an understanding of post-procedure instructions. It reflects awareness of the need to avoid introducing foreign substances into the vagina immediately after the procedure, which could interfere with the accuracy of the results or increase the risk of infection. By abstaining from douching or tampon use, the client follows recommended guidelines for post-Pap smear care, promoting optimal healing and accuracy of results.
Choice B rationale:
The statement, "I can resume sexual activity as soon as I leave the clinic," is incorrect and does not reflect an understanding of post-Pap smear instructions. Resuming sexual activity immediately after the procedure is not recommended, as it may increase the risk of infection or discomfort. The client should be advised to abstain from sexual activity for a specified period, typically recommended by the healthcare provider, to allow for proper healing and to minimize the risk of complications.
Choice C rationale:
The statement, "It’s normal to experience some mild cramping or spotting after the procedure," demonstrates an understanding of common post-Pap smear symptoms. Mild cramping and spotting are normal reactions to the procedure and are not typically indicative of a problem. By acknowledging these potential side effects, the client shows awareness of what to expect after the Pap smear and is better prepared to manage any discomfort that may arise.
Choice D rationale:
The statement, "I should call the clinic if I experience heavy bleeding or foul-smelling discharge," reflects an understanding of the importance of monitoring for signs of complications post-procedure. Heavy bleeding or foul-smelling discharge may indicate an infection or other issues that require prompt medical attention. By instructing the client to contact the clinic in such situations, the nurse ensures that the client knows how to respond appropriately to potential complications, promoting their overall well-being and timely intervention if necessary.
Choice E rationale:
The statement, "I can expect the results of my Pap smear in about 2-3 days," is incorrect and does not reflect an understanding of the typical timeline for receiving Pap smear results. Pap smear results usually take longer, often a week or more, to be processed and interpreted by the laboratory. Providing accurate information about result expectations is essential for managing the client's post-procedure anxiety and ensuring realistic expectations regarding follow-up.
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