Patient Data
Select the 4 assessment findings that require immediate follow up.
Severe abdominal pain in right lower quadrant
Blood pressure 115/76 mm Hg
Capillary refill 2 seconds
Radial and pedal pulses 2+1
Temperature 100.8° F (38.2° C)
Respirations 28 breaths/minute with shallow breathing
Feels anxious
Heart rate 121 beats/minute
Vomiting small amounts of green bile
Correct Answer : A,E,F,H
A. Severe abdominal pain in the right lower quadrant: This could indicate appendicitis, a surgical emergency, or another acute abdominal condition requiring immediate intervention. The sudden onset and severe nature of pain are concerning.
B. Blood pressure 115/76 mm Hg: This is within normal limits and does not indicate immediate instability.
C. Capillary refill 2 seconds: This indicates adequate peripheral perfusion and is not an urgent concern.
D. Radial and pedal pulses 2+: Normal peripheral pulses do not require immediate follow-up.
E. Temperature 100.8° F (38.2° C): Fever suggests an inflammatory or infectious process, such as appendicitis or another intra-abdominal infection.
F. Respirations 28 breaths/minute with shallow breathing: Increased respiratory rate and shallow breathing may indicate pain-related distress or developing peritonitis, a life-threatening complication of appendicitis.
G. Feels anxious: Anxiety may be a response to pain but is not an immediate concern requiring urgent intervention.
H. Heart rate 121 beats/minute: Tachycardia could be a response to pain, infection, or developing sepsis, which requires urgent evaluation.
I. Vomiting small amounts of green bile: While bile-stained emesis can indicate an obstruction, other findings (pain, fever, tachycardia, and respiratory distress) are higher priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
A. Lithium can increase parathyroid hormone (PTH) levels, worsening hyperparathyroidism.
B. Hydrochlorothiazide can raise calcium levels, further exacerbating hypercalcemia in hyperparathyroidism.
C. Sodium phosphate supplements can lower calcium levels, which may actually help, so it does not require immediate discussion.
D. Calcium carbonate can contribute to hypercalcemia and should be used cautiously.
E. Acetaminophen is safe and does not affect calcium levels.
Correct Answer is C
Explanation
A. Identify information as late entry in the record. This action would only be necessary after the issue is resolved and documentation is restored.
B. Print electronic medical record (EMR) from backup server. While printing from the backup server is an option, notifying IT should be done first to address the root cause of the issue.
C. Notify Information services department of the situation. The IT department can assist in troubleshooting the issue and restoring the system to normal function.
D. Wait for notification that the system has been rebooted. It’s important to act proactively by notifying IT to help resolve the problem.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.