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A nurse in a medical-surgical unit is caring for a client.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes
Day 1, 0330:
Client presents for evaluation of severe pain in upper abdomen that radiates into their back. States pain began approximately 12 hr ago and is worse when they are supine or after they eat. Rates pain as 7 on a scale of 0 to 10. Sclera noted to be yellow. Heart rate regular, lungs clear to auscultation. Abdomen firm, bowel sounds hypoactive. Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday. Reports no recent illnesses takes no prescribed medications. Client is alert and oriented x4.

Client presents for evaluation of severe pain in upper abdomen that radiates into their back.

States pain began approximately 12 hr ago and is worse when they are supine or after they eat.

Rates pain as 7 on a scale of 0 to 10. Sclera noted to be yellow.

Heart rate regular, lungs clear to auscultation.

Abdomen firm, bowel sounds hypoactive.

Client guards abdomen and grimaces during palpation. Reports last bowel movement was yesterday.

Reports no recent illnesses takes no prescribed medications.

Client is alert and oriented x4.

Answer and Explanation

The Correct Answer is ["A","B","C","E","F"]

Rationale for Correct Choices:

Pain radiating to the back, worsens after eating or lying down: This is characteristic of acute pancreatitis, where inflammation irritates surrounding tissues and worsens in the supine position due to gravitational pressure. Postprandial worsening suggests pancreatic enzyme stimulation.
Scleral icterus (yellow sclera and palate): Jaundice suggests biliary obstruction or liver involvement, possibly due to gallstone pancreatitis or alcoholic liver disease. This also aligns with the elevated bilirubin levels and warrants further hepatic and biliary assessment.
Abdomen distended, rigid, and tender with guarding: These are signs of peritonitis or severe intra-abdominal inflammation, requiring urgent evaluation. Guarding and rigidity indicate localized or diffuse peritoneal irritation from pancreatic enzymes.
Hypoactive bowel sounds: Reduced bowel activity is often seen in pancreatitis due to paralytic ileus caused by inflammation and stress response. Monitoring for progression to ileus or obstruction is necessary.
Client guards abdomen and grimaces during palpation: Guarding and pain upon palpation are signs of significant intra-abdominal inflammation. It may reflect worsening pancreatitis or complications such as necrosis or peritonitis.

Rationale for Incorrect Choices:

Heart rate regular, lungs clear to auscultation: These are normal findings and do not require follow-up.
Client is alert and oriented x4: Indicates normal neurologic status. No immediate concern here.
Reports no recent illnesses, takes no prescribed medications: This helps rule out medication-induced pancreatitis and doesn't indicate a need for follow-up.

Nursing Test Bank

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Correct Answer is C

Explanation

Rationale:

A. Fibrinogen level: Fibrinogen is a clotting factor that can reflect coagulation activity, but it is not used to monitor warfarin therapy. It is more relevant in conditions like DIC or liver disease, not for warfarin dose adjustments.

B. aPTT: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy. Warfarin, which affects the extrinsic pathway of coagulation, does not significantly impact aPTT levels.

C. INR: The international normalized ratio (INR) is the standard test used to monitor warfarin therapy. It reflects the effect of warfarin on prothrombin time and guides safe and effective dosing to maintain therapeutic anticoagulation.

D. Platelet count: While platelet count helps evaluate bleeding risk and detect thrombocytopenia, it is not used to guide warfarin dosing. Warfarin works by inhibiting vitamin K–dependent clotting factors, not by affecting platelet production.

A. Set up the sterile field 5 cm (2 in) below waist level. B. Place the cap from the solution sterile side up on a clean surface: C. Open the outermost flap of the sterile kit toward the body. D. Place the sterile dressing within 125 cm (0.5in) of the ledge of the sterile field.

Correct Answer is B

Explanation

Rationale:

A. Set up the sterile field 5 cm (2 in) below waist level: Sterile fields must be at or above waist level to maintain sterility. Anything below the waist is considered contaminated because it is out of the nurse’s visual field and control.

B. Place the cap from the solution sterile side up on a clean surface: The inside of the cap must face up to avoid contamination. Placing it on a clean surface with the sterile side up preserves sterility for recapping the solution if needed.

C. Open the outermost flap of the sterile kit toward the body: The first flap should be opened away from the body to prevent reaching over the sterile field, which increases the risk of contamination.

D. Place the sterile dressing within 1.25 cm (0.5 in) of the ledge of the sterile field: Items must be placed at least 2.5 cm (1 in) from the edge of the sterile field. The outer 1 inch is considered non-sterile and any item placed within this margin is no longer sterile.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the client's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?

Correct Answer is C

Explanation

A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?

Correct Answer is B

Explanation

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