A nurse is caring for a client in the intensive care unit.

Exhibits

The nurse is reviewing the admission assessment, nurses' notes, vital signs, and laboratory results. Drag words from the choices below to fill in each blank in the following sentence. The nurse identifies that the client's and can indicate the development of delirium.

A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.

B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.

C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."

D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.

A. The wall suction setting does not directly indicate the functioning of the NG tube.

B. Greenish-yellow drainage fluid may indicate the presence of bile in the stomach, suggesting

that the NG tube is not adequately draining gastric contents, which could indicate a malfunction.

C. An aspirate pH of 3 indicates gastric acidity, which is expected in the stomach and does not necessarily indicate a problem with NG tube function.

D. Abdominal rigidity may suggest intra-abdominal pathology but does not specifically indicate NG tube dysfunction.