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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 immediately to the provider?

Select all that apply.

Blood pressure

Mental confusion

Cold, clammy skin

Sodium level

Pain

Heart Rate

Serum amylase level

Respiratory status

Urine output

Temperature

Answer and Explanation

Correct Answer : A,B,C,F,G,I,J

A. The blood pressure dropped from 126/78 mm Hg on Day 1 to 80/60 mm Hg on Day 2. This change could signify worsening clinical status, potentially indicating shock or significant fluid loss.

B. The client's confusion and slow response can indicate a change in neurological status, possibly related to electrolyte imbalances, dehydration, or infection. This is a significant finding that requires immediate attention.

C. The client's skin changed from warm and dry to pale, cool, and clammy, suggesting possible shock or hypoperfusion. This is a critical sign that needs to be communicated to the provider.

D. The sodium level remains within normal limits (144 mEq/L) and does not show significant changes. Therefore, it does not require immediate reporting.

E. While the pain level increased from 3/10 to 6/10, pain itself is subjective and should be monitored closely. It may require adjustment in pain management but is not immediately life-threatening compared to other findings.

F. The heart rate increased from 90/min on Day 1 to 110/min on Day 2, indicating tachycardia. This can signify an underlying issue, such as hypovolemia or sepsis, especially given the other concerning findings.

G. The serum amylase level is significantly elevated on both days, with a sharp increase from 498 units/L to 1,058 units/L. This finding indicates potential pancreatitis or pancreatic injury, which can lead to serious complications. Given the clinical picture of worsening abdominal pain and elevated lipase (which also increased to 1,283 units/L), it is crucial to report this finding to the provider immediately.

H. The respiratory rate increased from 18/min to 22/min, indicating mild respiratory distress. While concerning, it does not represent an acute emergency compared to other findings and should be monitored.

I. The urine output decreased significantly from 400 mL over 8 hours to 100 mL over 6 hours, indicating possible acute kidney injury or dehydration.

J. The client’s temperature has increased from 37.2°C (99°F) to 38.4°C (101.1°F), indicating a possible infection or inflammatory response.

These findings indicate that the client may have severe acute pancreatitis, which can lead to systemic complications such as hypovolemia, shock, hypocalcemia, respiratory failure, and multiorgan failure.

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Correct Answer is D

Explanation

The correct answer is D.

Time of last pain medication. The nurse should include information that is relevant and essential for the continuity of care of the client, such as current assessment findings, interventions performed, response to treatment, and pending tests or procedures. The time of last pain medication is important to report because it affects the client's comfort level and mobility, and it helps the oncoming nurse plan when to administer the next dose of analgesia.

The steps required for dressing change are not necessary to report because they are usually standardized and documented in the policy manual or the care plan. The admission vital signs are not relevant to report because they do not reflect the client's current status. The preferred bath time is not essential to report because it can be obtained from the client or the chart.

A. Cover the wound with sterile, saline-soaked gauze. B. Raise the head of the bed to a 45° angle. C. Hold gentle, direct pressure on the protruding organ D. Place the client's knees in an extended position.

Correct Answer is A

Explanation

Covering the wound with sterile, saline-soaked gauze helps to prevent infection and keep the organ moist until surgical repair. Raising the head of the bed, applying pressure, and extending the knees can increase abdominal pressure and worsen the evisceration.

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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 immediately to the provider? Select all that apply.

Nursing Test Bank

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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 immediately to the provider?

Select all that apply.