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 A
Explanation
A. Overdose: The patient has ingested a large quantity of unknown pills, leading to severe metabolic acidosis, high anion gap, and possible toxic accumulation. Dialysis is often indicated to clear toxins in the case of overdose, especially if renal function is impaired (as indicated by elevated creatinine).
B. Chronic Kidney Disease: While chronic kidney disease may eventually require dialysis, the acute overdose and metabolic acidosis are the more immediate concerns requiring urgent dialysis.
C. Hypertension: Hypertension may require management, but it is not the primary reason to initiate urgent dialysis in this scenario. The overdose and metabolic acidosis take precedence.
D. Dehydration: Dehydration alone does not necessitate dialysis. However, the overdose, metabolic acidosis, and renal impairment are the critical reasons for initiating dialysis.
Correct Answer is B
Explanation
A. "Vomiting blood or material that looks like coffee grounds is a serious sign that I need to go to the emergency room." This is a correct understanding. Vomiting blood or coffee-ground material is a sign of gastrointestinal bleeding and requires immediate medical attention.
B. "If I experience severe abdominal pain, I should take an over-the-counter antacid and rest."
Taking an over-the-counter antacid without contacting a healthcare provider for severe pain could mask serious complications, such as recurrent bleeding or perforation, that need immediate medical attention. This statement indicates a need for further teaching.
C. "I should avoid taking NSAIDs like ibuprofen as they can increase my risk of bleeding." This is a correct understanding, as NSAIDs can cause or worsen gastric ulcers and increase the risk of bleeding.
D. "I should immediately report any black, tarry stools to my healthcare provider."This is a correct understanding. Black, tarry stools (melena) indicate upper gastrointestinal bleeding.
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