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Exhibits

Review H and P, nurse's note, laboratory results, and flow sheet.

Complete thee diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

  • Small intestinal obstruction is indicated by the client’s abdominal distension, absence of bowel sounds, refusal to eat, and episodes of vomiting. The laboratory results show metabolic acidosis (HCO3 of 16 mEq), which can be associated with a bowel obstruction.
  • Placing a nasogastric tube helps decompress the stomach and relieve pressure caused by the obstruction, while giving IV fluids helps to prevent dehydration and electrolyte imbalances that can occur with vomiting and obstruction.
  • Monitoring signs and symptoms of dehydration is crucial as the client has been vomiting and may not be able to maintain adequate fluid intake. Monitoring temperature is also essential to detect any signs of infection or complications related to the obstruction.


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Related Questions

Correct Answer is C

Explanation

A. Using another inhaler between doses may not align with the prescribed schedule for tiotropium, which is typically taken daily.
B. While reduced thickness of sputum is a desired outcome, it does not specifically indicate correct understanding of tiotropium use.
C. This statement indicates understanding, as tiotropium is a long-acting anticholinergic medication that should be used daily for maintenance therapy in COPD.
D. Tiotropium is not a rescue inhaler and should not be used for sudden shortness of breath; a short-acting bronchodilator is recommended for that situation.

Correct Answer is []

Explanation

Condition: The combination of severe abdominal pain, elevated inflammatory markers, and risk factors, along with the need for urgent care and surgical evaluation, suggests that GERD may be a significant underlying issue, especially in the context of potential complications.

Actions to Take

  1. Prepare for surgery: Given the client's presentation of severe abdominal pain, elevated white blood cell count, and possible abdominal rigidity, surgical intervention may be necessary to rule out conditions like acute cholecystitis or perforation.
  2. Transfer to high-risk level of care: Due to the client's elevated vital signs, including tachycardia and fever, along with the severe pain radiating to the shoulder, close monitoring in a high-risk area is warranted.

Parameters to Monitor

  1. Pain: Regular assessment of the client's pain level is crucial to evaluate the effectiveness of interventions and to monitor any changes in the severity of the pain.
  2. Signs and symptoms of abdominal perforation: Monitoring for indications such as increased abdominal tenderness, rigidity, fever, and changes in vital signs is essential to detect any complications promptly.

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