Exhibits

Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Nurses' Notes

1000:

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

A Pain typically occurs when the stomach is empty (1-3 hours after eating), often during the night and early morning. This pattern occurs because the presence of food helps to buffer gastric acid, whereas an empty stomach allows acid to directly contact the ulcerated area, leading to pain.

B. Pain in the right lower quadrant is not typically associated with peptic ulcer disease. Pain in PUD is usually located in the epigastric region (upper abdomen), although it can radiate to the back or other areas depending on the location and severity of the ulcer.

C. Constipation is not a typical finding in peptic ulcer disease. PUD is primarily associated with gastrointestinal symptoms related to acid-peptic imbalance, such as abdominal pain, bloating, nausea, and sometimes vomiting. Bowel habits are generally not directly affected by PUD.

D. In peptic ulcer disease, pain is usually relieved by eating or taking antacids. This is because food intake neutralizes gastric acid and provides a temporary protective coating over the ulcer, reducing irritation and pain.

B. This is often the nurse's top priority in the PACU. Anesthesia can depress respiratory function, leading to hypoventilation or airway obstruction. The nurse assesses respiratory rate, effort, oxygen saturation, and auscultates breath sounds to ensure adequate ventilation. Addressing any respiratory compromise promptly is crucial to prevent hypoxia or respiratory arrest.

A Assessing the surgical site is important to monitor for bleeding, infection, or any other complications related to the procedure. However, immediately after surgery, other assessments take precedence over this unless there is a specific concern like excessive bleeding or signs of infection.

C. Monitoring the client's level of consciousness is vital to detect any signs of neurological complications or delayed emergence from anesthesia. The nurse assesses orientation, responsiveness, and neurological signs to ensure the client is awakening appropriately from anesthesia.

D. Assessing pain is important as clients may experience discomfort after surgery. Pain can also affect respiratory function and overall recovery. However, it is typically assessed after ensuring respiratory status and consciousness are stable, as uncontrolled pain can be managed once immediate physiological concerns are addressed.