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 C
Explanation
A. Androgens (sex hormones): These are produced in the zona reticularis of the adrenal cortex. They contribute to the development of secondary sex characteristics and have a minor role compared to gonadal hormones.
B. Glucocorticoids (cortisol): Cortisol is synthesized in the zona fasciculata of the adrenal cortex. It regulates metabolism, immune responses, and the stress response, making it a key adrenal cortical hormone.
C. Epinephrine: This hormone is produced by the adrenal medulla, not the cortex. It plays a major role in the fight-or-flight response, increasing heart rate and blood glucose levels during stress.
D. Mineralocorticoids (aldosterone): Aldosterone is produced in the zona glomerulosa of the adrenal cortex. It is essential for sodium retention, potassium excretion, and blood pressure regulation.
Correct Answer is A
Explanation
A. Urine output <30mL/hour: Oliguria is defined as a markedly reduced urine output, typically less than 400 mL per day or less than 30 mL per hour. It indicates decreased kidney function or perfusion and is common in progressive renal conditions.
B. Absence of urine output: This describes anuria, not oliguria. Anuria is defined as urine output less than 100 mL per day and signifies severe kidney failure or complete urinary tract obstruction.
C. Increased urine output: This describes polyuria, often associated with conditions like uncontrolled diabetes mellitus or diabetes insipidus, not oliguria.
D. Urine output >100mL/hour: This is well above the threshold for oliguria and may suggest diuresis or overhydration. It does not meet the criteria for decreased kidney output.
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