The nurse is completing a focused gastrointestinal assessment.

The nurse auscultates the client's abdomen and hears 50 bowel sounds per minute.

The nurse documents this as

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. The nurse should anticipate the client to be experiencing

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.

Choice A rationale

Taking a fire extinguisher to the room follows the acronym PASS, but in the sequence of fire safety represented by the acronym RACE, extinguishing the fire is the very last step. The nurse must first ensure that the alarm is sounded to alert the entire facility and the fire department. Attempting to fight a fire before the alarm is activated could lead to the fire spreading unnoticed by others, which puts the entire building and all occupants at risk.

Choice B rationale

While calling 911 is an important part of emergency response, pulling the fire alarm is a faster and more efficient way to alert all personnel in a hospital setting. The fire alarm system is often directly linked to the fire department and simultaneously activates internal alerts and fire doors. Relying solely on a phone call may delay the immediate localized response needed to contain the situation. The alarm ensures that the specific location of the fire is identified.

Choice C rationale

According to the RACE acronym, which stands for Rescue, Alarm, Confine, and Extinguish, the second action after rescuing the client is to activate the fire alarm. This ensures that the fire department is notified and that all staff members are aware of the emergency. Promptly pulling the alarm allows the facility to begin its established fire protocols, which are essential for the safety of everyone in the building. It is the most critical next step.

Choice D rationale

Evacuating all clients on the nursing unit is a later step in the fire safety protocol, typically occurring if the fire cannot be contained or if ordered by the fire marshal. The immediate priority after removing the person in danger is to sound the alarm. Evacuation is a complex and high-risk process that should be coordinated based on the severity and location of the fire. Moving too many people prematurely can create chaos and block the access of emergency responders.

Choice A rationale

Purulent or excessive drainage from a wound is a critical cue indicating localized infection or impaired healing. In this client, the presence of drainage suggests the body is actively battling pathogens or trying to manage tissue necrosis. This finding must be monitored closely to prevent the progression to systemic sepsis. The character of the drainage, such as color and odor, provides essential information regarding the type of bacteria and the severity of the underlying inflammatory process.

Choice B rationale

The platelet count of 375,000/uL is marginally elevated above the standard reference range of 150,000 to 350,000/uL. While this can occur in response to inflammation or stress, it is not a primary concern or a specific indicator of acute danger for this patient. This mild thrombocytosis is generally considered a secondary or reactive finding and does not require urgent intervention or represent a high-priority clinical cue compared to signs of active infection or sepsis.

Choice C rationale

Fatigue is a common and non-specific symptom that can be associated with chronic illness, anemia, or the general metabolic demands of healing a chronic wound. While it is important to note, it does not provide specific diagnostic utility for acute infection or immediate physiological instability. In a patient with a chronic lower leg wound, fatigue is expected and is less concerning than objective clinical data like elevated white blood cell counts or systemic inflammatory markers.

Choice D rationale

A white blood cell count of 16,500/uL is significantly higher than the normal reference range of 4,000 to 10,000/uL. This leukocytosis is a major clinical cue signifying that the body is mounting an immune response to an infection or severe tissue injury. In the context of a chronic wound, such an elevation suggests that the infection is no longer localized and may be spreading, necessitating immediate further diagnostic evaluation and potentially more aggressive antibiotic therapy.

Choice E rationale

Documenting client allergies is a standard part of the nursing assessment and is vital for safety, particularly before administering new medications. However, in the context of identifying cues most concerning for the current acute issue, an allergy list is a baseline safety parameter rather than an active indicator of the patient's physiological status or the severity of their wound infection. It does not provide information about the current inflammatory or infectious state of the client.

Choice F rationale

Blood pressure is a key vital sign used to monitor hemodynamics. While it is important to monitor for signs of septic shock, such as hypotension, there is no indication in the data provided that the blood pressure is currently outside of the normal range or a primary concern. Until the blood pressure shows a significant deviation from baseline, it remains a routine monitoring parameter rather than a prioritized cue indicating an acute change in the client's infectious status.

Choice G rationale

The C-reactive protein level of 15 mg/dL is above the normal threshold of less than 10 mg/dL. This is a concerning cue because it is a sensitive biochemical marker of systemic inflammation. Elevated levels indicate that the wound is causing a significant inflammatory response within the body. Tracking this level helps clinicians evaluate the effectiveness of treatment, as the protein has a short half-life and will decrease rapidly once the inflammatory stimulus or infection is successfully controlled.

Choice H rationale

An elevated temperature is a systemic manifestation of the inflammatory response and is often triggered by pyrogens during an infection. It is a highly concerning cue as it indicates that the localized wound infection may be progressing to a systemic level. Fever increases the metabolic rate and oxygen consumption of tissues, which can be detrimental to a patient already struggling with wound healing. Monitoring temperature is essential for early detection of potential sepsis and systemic involvement.

Choice I rationale

While a pain rating is an important part of a comprehensive assessment, it is subjective and can be influenced by many factors, including the patient's previous experiences and pain tolerance. In chronic wound care, pain may be constant or related to dressing changes. While it must be managed for the client's comfort, it is generally considered less concerning than objective laboratory findings and physical cues that point directly to the presence of an acute and potentially dangerous infection.

Choice J rationale

The appearance of the wound, including redness, warmth, swelling, and the presence of necrotic tissue or purulent drainage, provides direct evidence of the local tissue environment. Changes in wound appearance are primary cues for diagnosing infection and determining the need for intervention. A wound that looks moist, red, or foul-smelling indicates active bacterial colonization and tissue breakdown, making it a high-priority cue that requires immediate attention from the healthcare team to prevent further complications.