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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 C

Explanation

Choice A reason:

Administer epinephrine subcutaneously. This is not the necessary action to be taken. Epinephrine is used to treat severe allergic reactions (anaphylaxis). However, in this case, the client is experiencing a febrile non-haemolytic transfusion reaction, not an allergic reaction.

Choice B reason:

Place the blood bag in a biohazard bag before discarding. This is not the necessary action to be taken by the nurse. Proper disposal of biohazardous materials is essential, but in this situation, the nurse's priority is to address the client's condition and not the disposal of the blood bag

Choice C reason:

Documentation of the transfusion reaction is crucial for the client's medical history and for future reference. The nurse should record the client's signs and symptoms, the actions taken, and any other relevant information related to the reaction.

Choice D reason

Infuse 500 ml lactated Ringer's IV.This is not necessary action to be taken by the nurse because there is no indication for infusing lactated Ringer's solution in response to the transfusion reaction described. Treatment for febrile non-haemolytic transfusion reactions generally involves stopping the transfusion, administering antipyretics (like acetaminophen) if necessary, and providing supportive care as needed.

A. Ballottement B. Chloasma C. Hegar's sign D. Chadwick's sign

Correct Answer is D

Explanation

The correct answer is D.

Chadwick's sign. Chadwick's sign is a bluish discoloration of the cervix, vagina, and vulva caused by increased blood flow to these areas during pregnancy. It usually appears around 6 to 8 weeks of gestation and persists until delivery. It is one of the presumptive signs of pregnancy, which are subjective changes that suggest pregnancy but are not conclusive. Ballottement is a technique of palpating the uterus to detect fetal movement when a finger is inserted into the vagina and tapped against the cervix. It can be performed between 16 and 28 weeks of gestation and is also a presumptive sign of pregnancy.

Chloasma is a condition characterized by brown patches on the face that may occur during pregnancy due to hormonal changes. It is also known as melasma or mask of pregnancy and usually fades after delivery. Hegar's sign is a softening of the lower uterine segment that can be felt during bimanual examination around 6 weeks of gestation. It is one of the probable signs of pregnancy, which are objective changes that strongly indicate pregnancy but are not diagnostic.

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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.

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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.