A nurse is caring for a male client on a medical-surgical unit.

Exhibits

Drag 1 condition and 1 client finding to fill in each blank in the following sentence.

The nurse suspects that the client has developed 

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based on

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.

A. Insertion of an endotracheal tube: Endotracheal intubation is outside the scope of practice for registered nurses. This procedure is performed by providers such as anesthesiologists, respiratory therapists, or specially trained advanced practice nurses.

B. Monitoring a continuous intra-arterial infusion of a thrombolytic medication: Nurses are responsible for closely monitoring patients receiving high-risk infusions. This includes assessing for complications such as bleeding, changes in vital signs, and effectiveness of therapy, which falls within an RN’s scope of practice.

C. Placement of nylon sutures: Suturing is a procedure performed by providers or advanced practice nurses, not registered nurses. Performing sutures is outside the RN’s scope of practice in most care settings.

D. Administering a bolus dose of medication through an epidural catheter: Epidural bolus administration requires advanced training and is usually limited to anesthesiologists, certified registered nurse anesthetists (CRNAs), or pain specialists.

Rationale for Correct Choices:
• Client reports abdominal pain as a 9 on a pain scale of 0 to 10: Severe abdominal pain indicates significant underlying pathology. In the presence of vomiting, distention, and altered bowel sounds, it could reflect obstruction, ischemia, or peritonitis, requiring urgent intervention.

• Abdomen is distended and firm: Distention and firmness suggest accumulation of gas or fluid within the abdomen. This is concerning for bowel obstruction or peritonitis, which can compromise circulation and lead to sepsis if untreated.

• Bowel sounds are distant and hypoactive: Diminished bowel sounds point to decreased peristalsis. In a client with abdominal pain and distention, this strongly suggests obstruction or ileus, requiring prompt diagnostic and therapeutic measures.

• Perianal skin is excoriated, and small ulceration is noted: Frequent diarrhea has led to skin breakdown and ulceration. This not only causes pain and discomfort but also increases the risk of secondary infection, requiring local wound care and protection.

• Tenting of skin for 4 seconds is noted: Delayed skin turgor indicates poor hydration status. Given this client’s vomiting, diarrhea, and low oral intake, this is a strong indicator of fluid volume deficit needing IV replacement.

• Temperature 38.7 °C (101.7 °F): Fever signals the presence of infection. With gastrointestinal complaints, this may be due to bacterial gastroenteritis, abscess formation, or other intra-abdominal infection that warrants further evaluation.

• Mucous membranes are dry: Dry mucous membranes reflect fluid volume depletion. This is consistent with the client’s history of poor intake, vomiting, and diarrhea, and further confirms dehydration.

Rationale for Incorrect Choices:

• Skin is warm and dry: Warm, dry skin suggests adequate peripheral perfusion and does not require follow-up compared to more urgent findings like dehydration and abdominal changes.

• Capillary refill is 2 seconds: A refill time under 3 seconds indicates sufficient peripheral circulation. This finding is within normal limits and does not require additional intervention.

• Respiratory rate 20/min: A respiratory rate within the range of 12–20 breaths/min is considered normal for adults. This shows stable respiratory function and does not require follow-up.