A nurse is caring for a client who has acute pancreatitis.
Vital Signs
Day 2:
Heart rate: 92/min
Respiratory rate: 20/min
BP: 122/58 mm Hg
Oxygen saturation: 96% on room air
Nurses Notes:
Oriented to person, place, and time; reports extreme fatigue.
Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago.
S1, S2 noted on auscultation. Pulses palpable.
Respirations even, unlabored. Chest clear on auscultation.
Bowel sounds hypoactive in all four quadrants. Client vomiting brown liquid and reports continuing nausea. Reports passing flatus. Urinating without difficulty, urine is clear yellow.
Heart rate: 92/min
Respiratory rate: 20/min
Oxygen saturation: 96% on room air
reports extreme fatigue.
Client rates pain as 3 on a 0 to 10 pain scale following administration of pain medication 30 min ago.
Respirations even, unlabored. Chest clear on auscultation.
Bowel sounds hypoactive in all four quadrants.
Client vomiting brown liquid and reports continuing nausea.
Reports passing flatus. Urinating without difficulty, urine is clear yellow.
The Correct Answer is ["A","B","C","E","F","I"]
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Heart rate: 92/min: Improved from 109/min on Day 1, showing better autonomic control.
A heart rate within normal range indicates reduced stress or inflammation. This suggests pain management and fluid status have improved. -
Respiratory rate: 20/min: Improved from 26/min, now within normal limits. This reflects decreased respiratory effort and better oxygenation. The labored breathing on Day 1 has also resolved.
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Oxygen saturation: 96% on room air: Increased from 93% on Day 1, indicating improved gas exchange. No supplemental oxygen was required, suggesting stable pulmonary function.
This is a positive sign especially given the initial diminished breath sounds. -
Client rates pain as 3/10 after medication: The pain is down from 8/10 on Day 1, showing effective analgesia. Pain control improves patient comfort and respiratory status. The pain was likely contributing to tachypnea and lethargy on Day 1.
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Respirations even and unlabored; chest clear on auscultation: Improved from "rapid, labored" with "diminished" breath sounds on day 1 which suggests resolution of respiratory compromise and pain-related restriction. Likely associated with improved oxygen saturation and decreased fatigue..
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Passing flatus: This indicates return of peristalsis and some bowel activity. These findings were not present on Day 1, showing progress. Flatus passage often precedes return to full bowel function.
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Urinating without difficulty; urine clear yellow: These findings indicate stable renal function, no hematuria or concentration issues. The findings were maintained across both days, with no signs of obstruction or dehydration which uggests effective fluid balance and kidney perfusion.
Rationale for Incorrect Findings:
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Bowel sounds hypoactive in all quadrants: No change from Day 1, suggests slow GI recovery. Hypoactivity may reflect paralytic ileus or continued inflammation.
Despite passage of flatus, bowel function remains impaired. -
Client vomiting brown liquid and reports continuing nausea: This is a new symptom on Day 2, worsening GI symptoms despite earlier improvement. Brown emesis may suggest delayed gastric emptying or possible GI bleeding.
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Reports extreme fatigue: Fatigue is more severe than Day 1's lethargy and may reflect nutritional deficits, systemic inflammation, or sleep disruption. Despite improved pain and respiratory status, overall energy is low.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Liver cirrhosis: Although chronic alcohol use can cause cirrhosis, the acute presentation with severe abdominal pain, fever, hypotension, and elevated amylase and lipase is more indicative of pancreatitis rather than cirrhosis, which typically presents with chronic symptoms.
B. Acute pancreatitis: Sudden severe abdominal pain, fever, low blood pressure, and elevated inflammatory markers like C-reactive protein along with elevated pancreatic enzymes (amylase and lipase) strongly suggest acute pancreatitis. Alcohol use is a common risk factor for this condition.
C. Hepatitis C: This usually presents with more chronic symptoms related to liver dysfunction fatigue, nausea, dark urine, and jaundice. It does not cause elevated pancreatic enzymes or acute abdominal pain.
D. Cholecystitis: While cholecystitis causes abdominal pain and fever, it does not typically cause elevated amylase and lipase levels unless there is associated pancreatitis. The vital signs and enzyme elevations point more directly to pancreatitis.
Correct Answer is C
Explanation
A. Imaging tests are likely to reveal scarring and deformation of the renal calices and pelvis: These findings are more typical of chronic pyelonephritis, which results from repeated or persistent kidney infections. Acute pyelonephritis usually presents with more subtle imaging changes.
B. Most cases of acute pyelonephritis are attributable to poorly controlled hypertension: While hypertension can complicate kidney disease, it is not a common cause of acute pyelonephritis. Most cases are due to ascending urinary tract infections, particularly from organisms like E. coli.
C. Flank pain, dysuria and nausea and vomiting are likely assessment findings: These are hallmark symptoms of acute pyelonephritis. Flank pain results from inflammation of the renal capsule, while dysuria and systemic symptoms like nausea, vomiting, and fever indicate infection.
D. The infection in the kidney is most likely a manifestation of a systemic infection: Acute pyelonephritis is typically caused by local ascending infections from the lower urinary tract, not systemic bacteremia. Though it can lead to systemic illness if not treated, its origin is usually localized.
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