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
Temperature
Blood pressure
Pain
Urine output
Heart rate
Respiratory status
Sodium level
Mental confusion
Serum amylase level
Cold, clammy skin
Correct Answer : A,B,E,F,H,J
A. Temperature: The client’s temperature increased from 37.2°C (99°F) to 38.9°C (102°F), indicating a possible infection or systemic inflammatory response. Fever in acute pancreatitis can suggest worsening inflammation, infection, or sepsis and should be reported immediately.
B. Blood pressure: The client's blood pressure dropped from 126/78 mmHg to 92/48 mmHg, indicating hypotension, which could be due to fluid shifts, systemic inflammation, or early shock. Immediate intervention is necessary to prevent hemodynamic instability.
C. Pain: While severe pain (rated 10/10) is expected in acute pancreatitis, it is not the most urgent concern requiring immediate reporting compared to hemodynamic instability and respiratory distress.
D. Urine output: The current urine output is not critically low (50-60 mL/hr), but continued monitoring is necessary. However, it is not an immediate life-threatening concern requiring urgent reporting.
E. Heart rate: The client’s heart rate increased from 90/min to 132/min, which is a significant tachycardia. This suggests compensatory shock, fluid loss, or worsening systemic inflammation and requires immediate provider notification.
F. Respiratory status: The respiratory rate increased from 18/min to 32/min, and oxygen saturation dropped to 88% on 3 L/min O₂. This suggests respiratory compromise, possibly due to worsening systemic inflammation, pleural effusion, or acute respiratory distress syndrome (ARDS).
G. Sodium level: The sodium level remains within the normal range (142 mEq/L; normal: 136-145 mEq/L), so it does not require immediate reporting.
H. Mental confusion: The client, who was alert on Day 1, is now disoriented. This change in mental status can indicate worsening systemic inflammation, hypoxia, or impending shock, requiring urgent intervention.
I. Serum amylase level: While elevated (498 units/L), this is expected in pancreatitis and does not require immediate notification unless there is a sudden drastic change.
J. Cold, clammy skin: This is a sign of poor perfusion and possible shock. It indicates worsening hemodynamic instability and requires immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Weight loss: Weight loss is not a sign of fluid overload; rather, it is more indicative of dehydration or insufficient nutritional intake. Fluid overload typically leads to weight gain due to the accumulation of excess fluid in the body, so weight loss would not be a manifestation of this condition.
B) Decreased skin turgor: Decreased skin turgor is a common sign of dehydration, not fluid overload. When a person is dehydrated, the skin loses its elasticity, and it takes longer to return to its normal position after being pinched. This is the opposite of what is seen in fluid overload, where excess fluid causes the skin to appear more swollen or taut.
C) Decreased blood pressure: Decreased blood pressure is more commonly associated with hypovolemia (low fluid volume) or dehydration, rather than fluid overload. In fluid overload, blood pressure may actually rise due to the increased volume of circulating blood, not decrease.
D) Crackles heard in the lungs: Crackles, or rales, heard in the lungs are a classic sign of fluid overload, particularly when the excess fluid accumulates in the lungs (pulmonary edema). This can occur due to the heart's inability to pump effectively, leading to fluid retention in the lungs. Therefore, crackles in the lungs are a key manifestation of fluid overload.
Correct Answer is B
Explanation
A) "I do not need to sign a consent form before this procedure": This statement is incorrect. Most procedures involving intravenous (IV) dye or contrast require the client to sign a consent form. This is because the procedure involves the use of a contrast agent that could have potential risks or side effects, and the client needs to be informed and give consent for its use.
B) "I will feel a warming sensation after the injection of the dye": This statement is correct. It is common for patients to experience a warming or flushing sensation after the injection of IV contrast dye. This feeling is typically temporary and a normal response to the dye being introduced into the bloodstream. The nurse should reassure the client about this sensation.
C) "I should limit my fluid intake for 2 days after the procedure": This statement is incorrect. In most cases, clients are encouraged to increase their fluid intake after procedures involving IV contrast to help flush the dye from their system and prevent any potential kidney complications. Limiting fluid intake is generally not recommended unless otherwise instructed by the healthcare provider.
D) "I can have a meal up to 2 hours before the procedure": This statement is incorrect in many cases, especially if the procedure involves sedation or anesthesia. Typically, clients are instructed to fast for a period (usually 4–6 hours) before procedures involving contrast dye, particularly if anesthesia or sedation is used. Eating too soon before the procedure can increase the risk of aspiration or other complications. It’s important to follow specific instructions from the healthcare provider.
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