A 45-year-old female patient is admitted to the emergency department with severe abdominal pain, fever, and nausea. She reports that the pain started suddenly and has progressively worsened. The healthcare provider suspects peritonitis and orders immediate interventions.
Physical examination
On examination, the patient has a distended abdomen, guarding, and rebound tenderness.
Her vital signs are as follows:
Temperature 102.4°F (39.1°C), Heart rate 120 bpm, Blood pressure 90/60 mmHg, and Respiratory rate 24 breaths per minute.
Which of the following complications is the nurse's highest priority to monitor for in this patient?
Intestinal obstruction
Hypovolemic shock
Electrolyte imbalance
Sepsis
The Correct Answer is B
A. Intestinal obstruction: While peritonitis can lead to intestinal obstruction, it is not the most immediate life-threatening complication compared to hypovolemic shock or sepsis.
B. Hypovolemic shock: This is a critical condition that can occur due to severe fluid loss, which might be a concern in peritonitis due to fluid shifts into the abdominal cavity. However, the patient’s signs of systemic infection (fever, elevated heart rate, low blood pressure) suggest that sepsis is a more imminent threat.
C. Electrolyte imbalance: Electrolyte imbalances are possible due to fluid loss, but they would be secondary to the more urgent concern of hypovolemic shock.
D. Sepsis: Sepsis is the highest priority due to the patient’s vital signs and symptoms indicating a systemic infection. Early recognition and treatment of sepsis are crucial to prevent organ failure and other severe complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Low back pain: While this can be a symptom of a UTI, it is not unique to older adults and can be seen in various age groups.
B. Confusion: In older adults, UTIs often present with atypical symptoms, such as confusion or delirium, rather than the classic symptoms like dysuria or frequency. This can be a sign of infection in this population.
C. Urinary retention: This is not specific to UTIs in older adults and can occur for other reasons, such as benign prostatic hyperplasia (BPH).
D. Incontinence: Although older adults may experience incontinence, it is not a unique sign of UTI and could be related to other conditions like weakened pelvic muscles.
Correct Answer is C
Explanation
A. Atorvastatin: Atorvastatin is a statin used to manage cholesterol levels. It is generally safe for use in patients with CKD.
B. Losartan: Losartan is an angiotensin II receptor blocker (ARB) used to manage hypertension and protect the kidneys in diabetic nephropathy. It can be beneficial in CKD patients.
C. Vancomycin: Vancomycin is an antibiotic known to be nephrotoxic, especially in patients with compromised kidney function. It should be used with caution or avoided in patients with CKD.
D. Aspirin: While aspirin can have adverse effects on the kidneys at high doses, its nephrotoxic potential is lower than that of vancomycin. In low doses, aspirin is commonly used for cardiovascular protection, even in patients with CKD.
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