A nurse in an urgent care facility is caring for a client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Potential Condition: Pancreatitis
Rationale:
The client's presentation with severe upper left quadrant abdominal pain, nausea, febrile status, tachypnea, and increased amylase and lipase levels suggests pancreatitis. Pancreatitis commonly presents with abdominal pain, nausea, and vomiting (though vomiting is not reported here), and elevated pancreatic enzymes (amylase and lipase). The elevated glucose level (200 mg/dL) may also point to pancreatitis since the pancreas plays a role in glucose metabolism.
Actions to Take:
Administer opioids for pain:
Rationale: Pain management is crucial in pancreatitis. Administering opioids like morphine or hydromorphone can help manage the severe pain, improving comfort and reducing distress.
Maintain separate equipment for the client:
Rationale: In cases of pancreatitis, particularly if caused by an infectious etiology, it is essential to avoid cross-contamination. Separate equipment reduces the risk of spreading infections if relevant.
Parameters to Monitor:
Dyspnea:
Rationale: The patient is tachypneic, and it's important to monitor for any progression of respiratory issues. Dyspnea could indicate worsening respiratory status or complications such as pleural effusion.
Hypotension:
Rationale: Hypotension can be a sign of shock, a potential complication of pancreatitis due to fluid loss, or systemic inflammatory response. It is important to monitor for signs of hypotension to ensure adequate perfusion and prevent shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D","E","F"]
Explanation
A. Instruct the client on the use of an incentive spirometer. Although this intervention can improve lung expansion, it is not a priority in this situation, given the possibility of an airborne infectious disease and the need to address systemic and diagnostic concerns first.
B. Request a glucocorticoid prescription from the provider. While glucocorticoids may reduce inflammation, there is no immediate indication they are necessary based on the client's presentation. The priority is diagnosing and managing the underlying infection.
C. Obtain blood cultures. Blood cultures are critical to identify any systemic infection that may be contributing to the client's fever, tachycardia, and worsening symptoms. This helps guide the initiation of appropriate antimicrobial therapy.
D. Obtain a sputum culture. The client’s productive cough with blood, fever, and weight loss raise suspicion for serious respiratory infections, such as tuberculosis (TB) or other pathogens. A sputum culture is necessary to identify the causative organism for targeted treatment.
E. Recommend ABGs be drawn. The client’s oxygen saturation has dropped to 92% on room air, and there is an increase in respiratory rate, indicating possible hypoxemia or impaired gas exchange. Arterial blood gases (ABGs) provide critical information about oxygenation, ventilation, and acid-base status, guiding further interventions.
F. Place the client in a negative-pressure room. The symptoms, including a cough producing blood-tinged sputum, fever, and weight loss, are consistent with a potential diagnosis of TB or another airborne infectious disease. A negative-pressure room prevents the spread of airborne pathogens to others.
G. Administer small, frequent meals. Although the client reports a lack of appetite and weight loss, this intervention is not urgent. Addressing the client’s infection and respiratory status takes precedence.
Correct Answer is C
Explanation
A. Return in two weeks for a follow-up MRI: MRI is generally contraindicated for clients with ICDs unless the device is MRI-compatible.
B. Expect to have a rapid pulse rate for the first few weeks: ICDs do not cause a sustained rapid pulse rate.
C. Wear loose-fitting clothing: Loose clothing prevents irritation and promotes healing of the surgical site, reducing the risk of infection.
D. Resume tub baths and swimming after 24 hr: Clients should avoid soaking the surgical site until fully healed.
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