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A nurse in a medical-surgical unit is caring for a clent

Exhibits

Complete the following sentence by using the lists of options.

The nurse should first address the

followed by the client .
Answer and Explanation

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

Rationale for Correct Choices:

  • Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
  • Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.

Rationale for Incorrect Choices:

  • Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
  • Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
  • Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
  • Blood glucose level:  Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.


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Related Questions

Correct Answer is A

Explanation

Rationale:

A. Methylprednisolone: Methylprednisolone is a corticosteroid, which can increase blood glucose levels by promoting gluconeogenesis and reducing insulin sensitivity. Hyperglycemia is a known adverse effect, especially with prolonged or high-dose use.

B. Ondansetron: Ondansetron is an antiemetic used to control nausea and vomiting. It does not affect glucose metabolism and is not associated with elevated blood glucose as a side effect.

C. Guaifenesin: Guaifenesin is an expectorant that thins mucus to improve airway clearance. It has no effect on blood sugar levels and is not known to interfere with glucose regulation.

D. Amoxicillin: Amoxicillin is a broad-spectrum antibiotic and does not typically cause changes in blood glucose. It is generally well-tolerated in terms of metabolic side effects.

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

Explanation

Rationale for Correct Choices:

  • Endometritis: Endometritis is a common postpartum infection of the uterine lining, often following cesarean birth, especially with risk factors like prolonged rupture of membranes and anemia. Clinical features include uterine tenderness, foul-smelling lochia, and fever, all of which are present in this case.
  • Uterus and lochia assessment: A uterus that is tender and slightly elevated, with moderate dark brown, malodorous lochia, is a hallmark of endometritis. The boggy fundus that firms with massage also suggests poor involution, frequently associated with infection.

Rationale for Incorrect Choices:

  • Mastitis: While the client reports breast discomfort, mastitis typically presents with unilateral breast pain, localized redness, and flu-like symptoms. The findings here are more consistent with engorgement than with infectious mastitis.
  • Pneumonia: The client has no respiratory distress, productive cough, or abnormal lung sounds (only slightly diminished bases), and oxygen saturation is normal. These signs are insufficient to support pneumonia.
  • Fever: Although fever is present (38.2°C), it is a nonspecific symptom that could occur with any postpartum infection or inflammation. It supports infection but does not localize the source as definitively as the uterine and lochia findings.
  • WBC count: The elevated WBC count (33,000/mm³) indicates infection or inflammation, but again, it is nonspecific. It supports the diagnosis but does not point solely to endometritis without clinical context from the uterus and lochia.

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