A nurse is assisting in the care of a newly admitted client.
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
Correct Answer : B,C,H
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.
Mental confusion and cold, clammy skin may suggest hypovolemia and shock due to fluid shifts from inflammation and necrosis of the pancreas.
Serum amylase and lipase levels are elevated in acute pancreatitis and reflect the extent of pancreatic damage. Respiratory status should be monitored closely as acute pancreatitis can cause pleural effusion, atelectasis, pneumonia, and acute respiratory distress syndrome (ARDS).
The nurse should also assess the client's pain, heart rate, temperature, and urine output as these are important indicators of the client's condition and response to treatment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Acetaminophen is a safer choice for pain relief in clients with cholelithiasis because it does not have significant effects on the gallbladder or biliary system. It can provide effective pain relief without exacerbating the underlying condition.
Choice B reason:
Omeprazole Omeprazole should not administer because it is a proton pump inhibitor (PPI) used to reduce stomach acid production and treat conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers. It is not indicated for the treatment of pain and discomfort associated with cholelithiasis.
Choice C reason
Should not be administered
Metoclopramide Metoclopramide should not be administered because it is a medication used to treat gastrointestinal issues such as nausea, vomiting, and gastroparesis. It is not indicated for the treatment of pain associated with cholelithiasis.
Choice D reason:
Ketorolac Ketorolac should not be administered because it is an NSAID used for moderate to severe pain. However, it should be avoided in clients with cholelithiasis due to its potential adverse effects on the gallbladder and biliary system.
Correct Answer is C
Explanation
The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.
The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.
The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.
The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.
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