A nurse is caring for a client who has acute pancreatitis.
Vital Signs
Day 2:
Heart rate: 92/min
Respiratory rate: 20/min
BP: 122/58 mm Hg
Oxygen saturation: 96% on room air
Nurses Notes:
Oriented to person, place, and time; reports extreme fatigue.
Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago.
S1, S2 noted on auscultation. Pulses palpable.
Respirations even, unlabored. Chest clear on auscultation.
Bowel sounds hypoactive in all four quadrants. Client vomiting brown liquid and reports continuing nausea. Reports passing flatus. Urinating without difficulty, urine is clear yellow.
Heart rate: 92/min
Respiratory rate: 20/min
Oxygen saturation: 96% on room air
reports extreme fatigue.
Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago.
Respirations even, unlabored. Chest clear on auscultation.
Bowel sounds hypoactive in all four quadrants.
Client vomiting brown liquid and reports continuing nausea.
Reports passing flatus. Urinating without difficulty, urine is clear yellow.
The Correct Answer is ["A","B","C","E","F","I"]
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Heart rate: 92/min: Improved from 109/min on Day 1, showing better autonomic control.
A heart rate within normal range indicates reduced stress or inflammation. This suggests pain management and fluid status have improved. -
Respiratory rate: 20/min: Improved from 26/min, now within normal limits. This reflects decreased respiratory effort and better oxygenation. The labored breathing on Day 1 has also resolved.
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Oxygen saturation: 96% on room air: Increased from 93% on Day 1, indicating improved gas exchange. No supplemental oxygen was required, suggesting stable pulmonary function.
This is a positive sign especially given the initial diminished breath sounds. -
Client rates pain as 3/10 after medication: The pain is down from 8/10 on Day 1, showing effective analgesia. Pain control improves patient comfort and respiratory status. The pain was likely contributing to tachypnea and lethargy on Day 1.
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Respirations even and unlabored; chest clear on auscultation: Improved from "rapid, labored" with "diminished" breath sounds on day 1 which suggests resolution of respiratory compromise and pain-related restriction. Likely associated with improved oxygen saturation and decreased fatigue..
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Passing flatus: This indicates return of peristalsis and some bowel activity. These findings were not present on Day 1, showing progress. Flatus passage often precedes return to full bowel function.
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Urinating without difficulty; urine clear yellow: These findings indicate stable renal function, no hematuria or concentration issues. The findings were maintained across both days, with no signs of obstruction or dehydration which uggests effective fluid balance and kidney perfusion.
Rationale for Incorrect Findings:
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Bowel sounds hypoactive in all quadrants: No change from Day 1, suggests slow GI recovery. Hypoactivity may reflect paralytic ileus or continued inflammation.
Despite passage of flatus, bowel function remains impaired. -
Client vomiting brown liquid and reports continuing nausea: This is a new symptom on Day 2, worsening GI symptoms despite earlier improvement. Brown emesis may suggest delayed gastric emptying or possible GI bleeding.
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Reports extreme fatigue: Fatigue is more severe than Day 1's lethargy and may reflect nutritional deficits, systemic inflammation, or sleep disruption. Despite improved pain and respiratory status, overall energy is low.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. High fiber diet, laxatives, increased water intake, increased reflex for defecation: These factors promote healthy bowel movements. Fiber adds bulk to stool, water softens it, laxatives stimulate movement, and an intact defecation reflex supports regular elimination, all of which prevent constipation.
B. Decreased fiber diet, decreased water intake, decreased reflex for defecation: These are contributing factors to constipation. However, it leaves out other significant causes like medications and medical conditions that impair bowel function.
C. Increased fiber diet, increased hydration, increased reflex for defecation, medications, absence of disease processes: Fiber, hydration, absence of disease and a strong reflex help prevent constipation. However, medications like opioids and anticholinergics often cause constipation regardless of diet and hydration.
D. Decreased fiber diet, decreased hydration, decreased reflex for defecation, medications, disease processes: A low-fiber diet and poor hydration lead to hard stools. A weak defecation reflex can result from neurological decline. Medications and chronic diseases such as diabetes or hypothyroidism can slow intestinal motility.
Correct Answer is A
Explanation
A. Esophageal: Esophageal variceal bleeding is the most common and serious complication of portal hypertension. Increased pressure in the portal venous system leads to the formation of varices in the esophagus, which can rupture and cause life-threatening hemorrhage.
B. Intestinal: While portal hypertension can cause changes in intestinal blood flow, it is not the most common site for clinically significant bleeding. Intestinal bleeding related to portal hypertension is much less frequent than esophageal variceal bleeding.
C. Duodenal: Duodenal bleeding is more commonly associated with peptic ulcer disease rather than portal hypertension. It is not a typical manifestation of increased portal venous pressure.
D. Rectal: Rectal bleeding may occur due to hemorrhoids or portal hypertensive colopathy, but it is less common and less life-threatening compared to esophageal varices in portal hypertension.
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