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Exhibits

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Nurses' Notes

1400:

Upon admission assessment, client is lying in the fetal position. Client reports abdominal pain as a 10 on a 0 to 10 scale and radiating to right shoulder. Abdomen is distended and rigid. During assessment, client vomited moderate amount bright red emesis.

Vital Signs

1400:

Temperature 36.5° C (97.7" F)

Heart rate 120/min

Respiratory rate 20/min

Blood pressure 70/49 mm Hg

SpO2 95% room air

client is lying in the fetal position

Client reports abdominal pain as a 10 on a 0 to 10 scale and radiating to right shoulder

Abdomen is distended and rigid

client vomited moderate amount bright red emesis

Temperature 36.5° C (97.7" F)

Heart rate 120/min

Respiratory rate 20/min

Blood pressure 70/49 mm Hg

SpO2 95% room air

Answer and Explanation

The Correct Answer is ["A","B","C","D","F","H"]

Rationales for Correct Findings:

Client lying in the fetal position; This position often indicates severe abdominal pain and discomfort, signaling peritoneal irritation or acute abdomen. It helps reduce tension on the abdominal muscles, which suggests significant underlying pathology such as peritonitis or perforation.
Abdominal pain rated 10 radiating to right shoulder: Shoulder pain, especially the right side, can be referred pain from diaphragmatic irritation caused by blood or gastric contents in the peritoneal cavity. This suggests a perforated ulcer or ruptured viscus, making it an alarming symptom requiring immediate attention.
Abdomen distended and rigid: Abdominal rigidity and distension are classic signs of peritonitis, which may result from gastrointestinal perforation or severe intra-abdominal infection. This indicates an emergency, as the patient may require surgery to address the underlying cause.
Vomited moderate amount bright red emesis: Bright red emesis indicates active upper gastrointestinal bleeding, which can lead to hypovolemia and shock. This finding requires prompt stabilization and diagnostic evaluation to control bleeding and prevent further deterioration.
Heart rate 120/min: Tachycardia is an early compensatory response to hypovolemia or pain and can be a sign of shock or sepsis. It indicates the body is under stress, and immediate monitoring and intervention are essential to prevent further cardiovascular compromise.
Blood pressure 70/49 mm Hg: Hypotension with a low systolic pressure indicates significant circulatory compromise, likely from blood loss or septic shock. This requires urgent fluid resuscitation and advanced cardiac monitoring to prevent organ failure.

Rationale for Incorrect Findings:

Temperature 36.5° C (97.7° F): The temperature is within normal limits, and the absence of fever does not rule out serious abdominal pathology. Fever may develop later in peritonitis or infection, so normal temperature should not delay intervention but does not require immediate follow-up alone.
Respiratory rate 20/min: This respiratory rate is within normal to mildly elevated range and may reflect mild distress but is not critical at this time. Oxygen saturation is adequate, and the patient is breathing without significant difficulty, so no urgent intervention based solely on this is needed.
SpO2 95% room air: Oxygen saturation at 95% on room air is borderline but generally acceptable in adults without respiratory disease. It does not indicate respiratory failure and is not the priority concern in this clinical scenario.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Insert an indwelling urinary catheter: This may be necessary to monitor fluid output after diuretic therapy, but it is not the immediate priority when oxygenation is compromised due to fluid in the lungs.
B. Administer an IV diuretic: Diuretics help reduce fluid overload, which is key in managing pulmonary edema, but oxygenation must be addressed first to stabilize the client and prevent hypoxia.
C. Initiate oxygen via face mask: The most urgent concern in acute pulmonary edema is impaired gas exchange. Administering oxygen immediately helps improve oxygenation and is the priority intervention to address life-threatening hypoxia.
D. Request an analysis of ABGs: While ABG results are important to assess respiratory function and guide further treatment, drawing labs takes time. Oxygen administration should not be delayed in order to obtain lab values.

A. Institutional policies and procedures B. Verbal direction from the nurse manager C. State Nurse Practice Act D. Written prescription from the provider

Correct Answer is C

Explanation

A. Institutional policies and procedures: While institutional policies provide guidance on how tasks are performed within a facility, they cannot legally expand or limit a nurse’s scope of practice. Nurses must always ensure tasks are permitted by state law first.
B. Verbal direction from the nurse manager: Managers may offer direction, but their guidance should not override legal regulations. Relying solely on verbal instructions risks performing tasks outside the legal scope of practice, which can lead to liability issues.
C. State Nurse Practice Act: The Nurse Practice Act is a legal document specific to each state that defines the scope of practice for nurses. It outlines what tasks are legally permissible and serves as the most authoritative reference for professional responsibilities.
D. Written prescription from the provider: Although a provider can order treatments or procedures, nurses are still responsible for ensuring those actions fall within their legal scope. Following a prescription without verifying legality may result in practicing beyond licensure.

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