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A nurse is assisting in the care of a newly admitted client.

Exhibits

Which of the following findings should the nurse report immédiately to the provider?Select all that apply.

A.

Urine output

B.

Heart rate

C.

Sodium level

D.

Respiratory status

E.

Pain

F.

Serum amylase level

G.

Mental confusion

H.

Blood pressure

I.

Temperature

J.

Cold, clammy skin

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

A. Discontinue this medication if this occurs again. Stopping a newly prescribed medication without consulting a provider is not recommended. Many medications, including antihypertensives, can cause lightheadedness, and adjustments or precautions should be discussed with a healthcare provider rather than discontinuing the drug independently.
B. Sit back down for a few minutes when this occurs. Lightheadedness upon standing is often due to orthostatic hypotension, which can be managed by sitting back down to allow blood pressure to stabilize. Slowly changing positions, staying hydrated, and rising gradually can also help minimize symptoms.
C. Restrict your daily fluid intake. Reducing fluid intake can worsen symptoms of orthostatic hypotension by decreasing blood volume, leading to further drops in blood pressure. Instead, maintaining adequate hydration is essential to support circulatory stability and prevent dizziness.
D. Take a daily potassium supplement. Unless there is a confirmed potassium deficiency, supplementation is unnecessary and could lead to hyperkalemia, especially if the client is on medications affecting potassium levels. Lightheadedness is more commonly related to blood pressure changes rather than potassium imbalances.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

Anticipated:

  • Apply a cool compress to the extremity. A cool compress can reduce swelling, relieve discomfort, and help minimize the tightness in the skin caused by edema. The cold temperature helps constrict blood vessels, reducing fluid buildup in the tissues. This intervention is appropriate for managing IV infiltration-related symptoms.
  • Assist in inserting a new IV catheter in a site distal to the infiltration site. If the IV site becomes infiltrated, the correct approach is to stop the current infusion and insert a new catheter in a different location, preferably distal to the infiltration site. This ensures continued IV access without further aggravating the infiltrated site.
  • Elevate extremity. Elevating the affected extremity can help reduce swelling by promoting venous return. Elevation improves circulation and decreases the pressure caused by fluid accumulation in the tissues. This is an effective intervention for managing swelling in the right upper extremity due to infiltration.

Not Anticipated:

  • Phytonadione (vitamin K) is typically used to reverse the effects of anticoagulation medications or treat vitamin K deficiency. This is not indicated for the client, as there is no evidence of bleeding or an anticoagulation issue that requires vitamin K. The client's current problem is an IV infiltration, not a clotting disorder.
  • Send the catheter tip for culture. At this point, there are no signs of infection such as redness, warmth, or discharge from the IV site. The primary concern is managing the infiltration, so sending the catheter tip for culture is unnecessary unless infection is suspected. Culture collection is reserved for cases where an infection is present.
  • Suggest irrigating the IV catheter. Irrigating an infiltrated IV catheter could worsen the situation by pushing fluids further into the surrounding tissue or introducing bacteria. The proper action is to discontinue the infusion, remove the IV, and insert a new catheter at a different site rather than attempting to irrigate an already compromised catheter.

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