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 : 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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","F"]
Explanation
The nurse is responsible for educating the client and their partner about advance directives and facilitating their decision-making process. Advance directives are legal documents that allow the client to express their preferences for medical care and treatments at the end of life.
They also enable the client to appoint a health care proxy, who is a person who can make health care decisions for the client if they are unable to do so themselves.
The nurse should provide the client with written information about advance directives, document that the provider discussed do-notresuscitate status with the client, and communicate advance directives status via the medical record and shift report.
The nurse should not instruct the client that an advance directive is a legal document and must be honored by care providers, as this may imply coercion or limit the client's right to change their mind.
The nurse should also not inform the client that an advance directive discontinues further care, as this is inaccurate and may discourage the client from completing one.
The nurse should facilitate a power of attorney for health care document only if the client wishes to designate a health care proxy.
Correct Answer is D
Explanation
The correct answer is D.
Reduced fat in the stools. Pancrelipase is a medication that replaces digestive enzymes produced by the pancreas, which are lacking in most people with cystic fibrosis due to excess mucus production that clogs the pancreatic ducts. By taking pancrelipase, the child can improve their digestion of food and absorb more nutrients, especially fat and fat-soluble vitamins. This will result in reduced fat in the stools, which is a sign of pancreatic insufficiency.
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