A nurse is assisting in the care of a newly admitted client.
Which of the following findings should the nurse report immédiately to the provider?Select all that apply.
Urine output
Heart rate
Sodium level
Respiratory status
Pain
Serum amylase level
Mental confusion
Blood pressure
Temperature
Cold, clammy skin
Correct Answer : B,D,G,H,J
Rationale for Correct Options:
- Heart rate. The heart rate has increased from 90/min on Day 1 to 132/min on Day 2. This significant elevation is concerning for worsening systemic inflammation, hypovolemia, or sepsis and requires immediate intervention.
- Respiratory status. The client initially had diminished breath sounds at the lung bases, but by Day 2, breath sounds are diminished throughout. This suggests worsening respiratory function, possibly due to acute respiratory distress syndrome (ARDS) or pleural effusion, both of which can complicate severe pancreatitis. Immediate assessment and intervention are necessary.
- Mental confusion. The client was alert and oriented on Day 1 but is now disoriented to person, place, and time on Day 2. This change in mental status can indicate worsening systemic inflammation, sepsis, hypoxia, or metabolic disturbances such as hypocalcemia. Immediate evaluation is needed.
- Blood pressure. While the client’s initial blood pressure was stable at 126/78 mm Hg, the current reading is not provided. If the client is experiencing hypotension, it could indicate worsening shock, requiring urgent intervention.
- Temperature. The client’s temperature increased from 37.2 °C (99 °F) on Day 1 to 38.9 °C (102 °F) on Day 2. This suggests a developing infection, such as infected pancreatic necrosis or sepsis, which requires immediate reporting and further evaluation.
- Cold, clammy skin. Cold, clammy skin is a sign of poor perfusion, which may indicate impending shock due to worsening sepsis or hypovolemia. This is an urgent finding requiring immediate attention.
Rationale for Incorrect Options:
- Urine output. The client’s urine output was documented as 60 mL/hr, which is within the normal range. There is no indication of oliguria or anuria that would require immediate reporting.
- Sodium level. The sodium level of 142 mEq/L is within the normal range and does not indicate a critical electrolyte imbalance requiring urgent intervention.
- Pain. The client’s pain has increased from 8/10 to 10/10 despite receiving morphine via a PCA pump. While pain management is crucial, worsening pain alone is not the most urgent concern compared to systemic complications like respiratory failure or hemodynamic instability.
- Serum amylase level. Although the serum amylase level is significantly elevated at 498 units/L, this is expected in acute pancreatitis and does not necessarily indicate an immediate life-threatening emergency. Trends in amylase and lipase levels are important for monitoring, but they do not require urgent reporting unless accompanied by other signs of deterioration.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtain written consent by the client for the placement of the restraints. It is not typically required to obtain written consent from the client for the use of restraints. However, consent may be necessary for treatment in general, depending on the facility's policies and state laws. Restraints are usually applied to ensure safety and must be justified based on the client's behavior.
B. Release the client's restraints every 4 hr. Restraints should be released more frequently, typically every 1 to 2 hours, to assess the client's safety and physical condition and to allow for movement, hydration, and toileting as appropriate.
C. Document the client's behavior leading to the initiation of the restraints. Documenting the client's behavior that necessitated the use of restraints is crucial for legal and ethical reasons. This documentation provides a clear rationale for the use of restraints and helps ensure compliance with facility policies and regulations.
D. Check the client's status every hour. The client's status should be checked more frequently than every hour. Regular monitoring is essential to ensure the client's safety, comfort, and physical well-being while in restraints. The nurse should assess the client every 15 to 30 minutes based on facility protocols.
Correct Answer is B
Explanation
A. Place the client in a room with a high-efficiency particulate air (HEPA) filter. HEPA filtration is used for airborne precautions, such as tuberculosis. MRSA is transmitted through direct contact, so a private room or cohorting with another MRSA-positive client is sufficient.
B. Don gloves prior to assisting the client with brushing their teeth. MRSA is primarily spread via direct contact with infected wounds, secretions, or contaminated surfaces. Wearing gloves when providing personal care helps prevent transmission.
C. Ensure that the negative air pressure is active for the client's room. Negative pressure rooms are necessary for airborne pathogens like tuberculosis or measles. MRSA does not require airborne precautions, so this is not needed.
D. Have the client wear a mask when they are out of their room. A mask is only required if MRSA is present in the respiratory tract and the client has a productive cough. Standard contact precautions, such as hand hygiene and personal protective equipment, are the primary infection control measures.
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