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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

Temperature

Blood pressure

Pain

Urine output

Heart rate

Respiratory status

Sodium level

Mental confusion

Serum amylase level

Cold, clammy skin

Answer and Explanation

Correct Answer : A,B,E,F,H,J

A. Temperature: The client’s temperature increased from 37.2°C (99°F) to 38.9°C (102°F), indicating a possible infection or systemic inflammatory response. Fever in acute pancreatitis can suggest worsening inflammation, infection, or sepsis and should be reported immediately.
B. Blood pressure: The client's blood pressure dropped from 126/78 mmHg to 92/48 mmHg, indicating hypotension, which could be due to fluid shifts, systemic inflammation, or early shock. Immediate intervention is necessary to prevent hemodynamic instability.
C. Pain: While severe pain (rated 10/10) is expected in acute pancreatitis, it is not the most urgent concern requiring immediate reporting compared to hemodynamic instability and respiratory distress.
D. Urine output: The current urine output is not critically low (50-60 mL/hr), but continued monitoring is necessary. However, it is not an immediate life-threatening concern requiring urgent reporting.
E. Heart rate: The client’s heart rate increased from 90/min to 132/min, which is a significant tachycardia. This suggests compensatory shock, fluid loss, or worsening systemic inflammation and requires immediate provider notification.
F. Respiratory status: The respiratory rate increased from 18/min to 32/min, and oxygen saturation dropped to 88% on 3 L/min O₂. This suggests respiratory compromise, possibly due to worsening systemic inflammation, pleural effusion, or acute respiratory distress syndrome (ARDS).
G. Sodium level: The sodium level remains within the normal range (142 mEq/L; normal: 136-145 mEq/L), so it does not require immediate reporting.
H. Mental confusion: The client, who was alert on Day 1, is now disoriented. This change in mental status can indicate worsening systemic inflammation, hypoxia, or impending shock, requiring urgent intervention.
I. Serum amylase level: While elevated (498 units/L), this is expected in pancreatitis and does not require immediate notification unless there is a sudden drastic change.
J. Cold, clammy skin: This is a sign of poor perfusion and possible shock. It indicates worsening hemodynamic instability and requires immediate intervention.

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Free Nursing Study Resources

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

Explanation

Administer phytonadione (Vitamin K): Contraindicated

There is no indication that the client has a bleeding disorder or is on anticoagulant therapy requiring Vitamin K. This intervention is not relevant to the client's condition.

Apply cool compress to the extremity: Anticipated

A cool compress helps reduce pain and swelling associated with IV infiltration by constricting blood vessels and limiting the spread of IV fluid into surrounding tissues.

Elevate extremity: Anticipated

Elevation promotes venous return and reduces edema in the infiltrated extremity, aiding in symptom relief and tissue recovery.

Suggest irrigating the IV catheter: Contraindicated

Flushing or irrigating an infiltrated IV catheter could worsen tissue damage by forcing more fluid into the surrounding area. The catheter should be removed immediately.

Assist in inserting a new IV catheter in a site distal to the infiltration site: Contraindicated

A new IV should be placed proximal (above) rather than distal to the infiltration site to ensure proper circulation and avoid further infiltration.

Send the catheter tip for culture: Anticipated

Given the client’s edema, pain, and potential IV infiltration, infection is a concern. Sending the catheter tip for culture helps rule out phlebitis or IV-related infection.

A. Turn on overhead lights briefly when checking IV line B. Open curtains between clients semiprivate rooms C. Conduct change-of-shift report near the clients’ rooms. D. Wear shoes with rubber soles

Correct Answer is D

Explanation

A) "Turn on overhead lights briefly when checking IV line.": Turning on overhead lights can disrupt the client’s sleep, especially if done during the night. Light exposure can interfere with the body’s natural circadian rhythm, making it harder for the client to fall asleep and stay asleep. A more appropriate action would be to use a dim light or portable light to minimize disturbance.

B) "Open curtains between clients’ semiprivate rooms.": Opening the curtains between semiprivate rooms could increase noise and visual distractions, which may disturb the client's sleep. Keeping the environment as calm and private as possible is essential to reduce stress and promote restful sleep. Curtains should ideally remain closed to promote privacy and minimize distractions.

C) "Conduct change-of-shift report near the clients’ rooms.": Conducting report near the client's rooms can create unnecessary noise and disturb the client’s sleep. The change-of-shift report should ideally take place in a designated area, away from patient rooms, to reduce noise and disturbances in the environment.

D) "Wear shoes with rubber soles.": Wearing shoes with rubber soles reduces noise when walking, which is particularly important in an acute care setting where patients need rest. Quiet movement helps to maintain a peaceful environment, reducing the environmental stressors that can impact sleep quality for clients.

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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

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

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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