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The nurse has reviewed the Graphic Record  and Diagnostic Results at 1030.

Complete the following sentence by using the lists of options.

The nurse should first address the client's

followed by the client's .
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

  • Lung sounds: The client is exhibiting slight inspiratory wheezes, suggesting airway narrowing that could worsen quickly, particularly with a history of asthma. Following the ABC priority framework (Airway, Breathing, Circulation), any compromise in breathing must be assessed and managed first to prevent respiratory decline.
  • Bowel sounds: Although bowel sounds are hyperactive, they do not immediately threaten life or stability. They are typically monitored rather than prioritized unless accompanied by severe gastrointestinal symptoms like obstruction.
  • Heart rate: Tachycardia is present but mild at 104/min and not currently associated with hypotension or hypoxia. While important to monitor, it is a secondary concern after ensuring airway patency and addressing breathing issues.
  • Anxiety: Anxiety may be contributing to elevated heart rate and hyperactive bowel sounds but does not represent an immediate physiological risk. Emotional support is important but should be provided after stabilizing airway and circulation.
  • Vaginal spotting: Vaginal spotting, especially in early pregnancy with abdominal tenderness, raises concern for ectopic pregnancy. After securing the airway, the next concern would be assessing for ongoing or worsening vaginal bleeding, which could signify internal hemorrhage.
  • Hemoglobin: The client's hemoglobin is low-normal (11 g/dL), suggesting mild anemia, possibly from chronic or early bleeding. However, there are no signs of active major blood loss requiring emergent correction, so it would not take immediate precedence over bleeding evaluation.


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Related Questions

Correct Answer is B

Explanation

A: Location A is near the infant’s foot, specifically around the ankle. This area is where the posterior tibial or dorsalis pedis pulse would be palpated, not the femoral pulse. These pulses are important for assessing peripheral circulation but are not the primary site for evaluating coarctation of the aorta, which requires checking central pulses like the femoral.

B: Location B is at the upper inner thigh, near the groin, where the femoral artery passes close to the skin surface. This is the correct site for palpating the femoral pulse in an infant. In conditions like coarctation of the aorta, comparing the strength of the brachial and femoral pulses is crucial to detect differences in blood flow between the upper and lower body.

C: Location C is on the upper arm, near the shoulder area, which corresponds to the location for checking the brachial pulse. The brachial pulse is commonly used in infants to assess heart rate, especially during resuscitation efforts. However, it is not the site for assessing femoral pulse strength, which is needed when evaluating for coarctation of the aorta.

Correct Answer is D

Explanation

A. Difficulty swallowing: Difficulty swallowing, or dysphagia, is not typically a direct indicator of unrelieved pain. It could suggest neurological or throat-related issues rather than being a primary symptom associated with inadequate pain control.

B. Constipation: Constipation is a common postoperative complication, often related to anesthesia, immobility, or opioid use. While it is important to address, it does not directly reflect the client's current pain level or effectiveness of pain management.

C. Urinary retention: Urinary retention can occur due to anesthesia effects, pelvic surgery, or opioid administration. Although it is a significant postoperative concern, it is not a reliable or direct indicator of unrelieved pain.

D. Restlessness: Restlessness is a common sign of unrelieved pain, particularly in postoperative clients. When clients are uncomfortable or in significant pain, they may appear restless, anxious, or unable to remain still, signaling the need for further pain assessment and intervention.

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