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. Increase their intake of cranberry juice and other fluids: While cranberry juice and increased fluids may help prevent or relieve mild urinary tract infections, the presence of blood in the urine (hematuria) and lower abdominal pain may indicate a more serious condition that requires professional evaluation rather than home remedies alone.
B. Wait and see if it goes away without treatment: Ignoring hematuria and pain can delay diagnosis and treatment of potentially serious conditions such as infections, stones, or other urinary tract problems. Prompt assessment is important to prevent complications.
C. Go to the emergency room right away: Unless symptoms are severe, such as uncontrollable pain, fever, or signs of systemic infection, immediate emergency care may not be necessary. However, timely medical evaluation is still essential.
D. Get an appointment with their family provider: This is the most appropriate advice because a healthcare provider can perform necessary assessments, such as history, physical exam, and diagnostic tests, to determine the cause of hematuria and pain and initiate appropriate treatment.
Correct Answer is D
Explanation
A. Acute renal disease–acute glomerulonephritis: This leads to inflammation and damage of the glomerular basement membrane, impairing filtration and causing intrarenal injury. It often presents with hematuria, proteinuria, and hypertension.
B. Exposure to nephrotoxic drugs, heavy metals, and organic solvents: These substances damage renal tubules through direct toxicity or by causing crystal formation, leading to acute tubular necrosis. Common agents include aminoglycosides and contrast dyes.
C. Prolonged renal ischemia: Sustained low perfusion causes tubular cell death and sloughing, leading to obstruction and decreased GFR. It is often a progression from untreated prerenal AKI.
D. Liver failure: Liver dysfunction reduces renal perfusion and may cause hepatorenal syndrome, but this is classified as prerenal, not intrarenal, in origin. The kidneys are structurally intact but functionally impaired.
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