The nurse gets hand-off report on four patients. Which patient would the nurse assess first?

Patient with urine output of 40 mL/hr for the last hour.

Patient with a blood pressure change of 128/74 to 110/88 mmHg.

Patient with oxygen saturation maintained at 94%.

Patient with a pulse change of 100 to 88 beats/min.

Answer and Explanation

The Correct Answer is B

Choice A reason: A urine output of 40 mL/hr is within the acceptable range, as normal urine output is typically around 30-50 mL/hr. While it should be monitored, it does not indicate an immediate life-threatening issue requiring urgent assessment.

Choice B reason: A blood pressure change from 128/74 to 110/88 mmHg may indicate potential hemodynamic instability. Although the systolic blood pressure has decreased, the diastolic pressure has increased, which can be concerning. This patient may be at risk for developing more significant blood pressure changes or other complications, making this situation the highest priority for assessment.

Choice C reason: An oxygen saturation level of 94% is generally considered acceptable. While it is on the lower end of the normal range, it does not indicate an immediate life-threatening condition. Continuous monitoring is important, but it is not the most urgent situation compared to the blood pressure change.

Choice D reason: A pulse change from 100 to 88 beats/min represents a decrease in heart rate but remains within the normal range for adult heart rate (60-100 beats/min). While this change should be noted and monitored, it is not as urgent as the blood pressure change that may indicate hemodynamic instability.

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Correct Answer is ["A","B","E","F"]

Explanation

Choice A reason: Fever is a common sign of acute pancreatitis and indicates an inflammatory response. Inflammation of the pancreas can trigger the release of cytokines and other inflammatory mediators, leading to an elevated body temperature. This is a common symptom observed in many cases of acute pancreatitis and suggests an ongoing inflammatory process.

Choice B reason: Gray-blue discoloration of the flank or umbilical area, also known as Grey Turner's sign and Cullen's sign respectively, indicates bleeding and severe inflammation within the pancreas. These signs are indicative of retroperitoneal hemorrhage or pancreatic necrosis, which are severe complications of acute pancreatitis. The presence of such discoloration is a significant finding that suggests a more serious form of the condition.

Choice C reason: Hypertension is not typically associated with acute pancreatitis. In fact, patients with acute pancreatitis are more likely to experience hypotension due to fluid shifts, inflammatory responses, and potential hemorrhage. Monitoring blood pressure is important in these patients to manage any potential complications.

Choice D reason: Decreased amylase level is not an expected finding in acute pancreatitis. Typically, acute pancreatitis is associated with elevated levels of pancreatic enzymes such as amylase and lipase due to inflammation and damage to the pancreatic cells, which release these enzymes into the bloodstream.

Choice E reason: Nausea and vomiting are common symptoms in acute pancreatitis. The inflammation of the pancreas and the associated pain can stimulate the vomiting center in the brain and lead to nausea and vomiting. These symptoms are often severe and can significantly affect the patient's comfort and hydration status.

Choice F reason: Severe abdominal pain is one of the hallmark signs of acute pancreatitis. The pain is typically located in the upper abdomen and may radiate to the back. It is often described as constant and severe, and can be exacerbated by eating or lying flat. Effective pain management is a critical aspect of caring for patients with acute pancreatitis.

A. The client's albumin level is increased. B. The client's platelet count is normal. C. The dressing has a 2-cm area of serous drainage. D. The client's heart rate is 122 beats/min.

Correct Answer is D

Explanation

Choice A reason: An increased albumin level, while noteworthy, is not typically an urgent finding to communicate immediately following paracentesis. Albumin levels can fluctuate for various reasons, and elevated levels do not generally indicate a critical issue requiring immediate intervention.

Choice B reason: A normal platelet count is a good sign, indicating that the patient has an adequate number of platelets for blood clotting and wound healing. This finding does not indicate an urgent need to notify the healthcare provider immediately.

Choice C reason: A 2-cm area of serous drainage on the dressing is relatively small and expected after a procedure like paracentesis. It suggests that the site is draining some fluid, which is normal post-procedure. While it should be monitored, it does not necessitate urgent communication unless it worsens or there are signs of infection.

Choice D reason: A heart rate of 122 beats/min is tachycardia and can indicate several potential complications, including hypovolemia (low blood volume) due to the large fluid removal, infection, or other stressors on the patient's body. This finding is the most critical to communicate to the healthcare provider promptly as it may require immediate intervention to address the underlying cause and stabilize the patient.

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The nurse gets hand-off report on four patients. Which patient would the nurse assess first?

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Naxlex Comprehensive Predictor Exams

The emergency department nurse can expect to see which assessment cues in the patient with acute pancreatitis? Select all that apply.

Correct Answer is ["A","B","E","F"]

Explanation

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the healthcare provider (HCP)?

Correct Answer is D

Explanation

A 76-year-old patient is 2 days post-op total hip replacement. The patient puts his call light on to complain of difficulty catching his breath. As the nurse assesses the patient, she finds the patient tachypneic, tachycardic, and very anxious. The nurse determines these are most likely signs of:

The nurse notes that a client with acute pancreatitis occasionally experiences muscle twitching and jerking. How should the nurse interpret the relevance of these symptoms?

The nurse should anticipate which of these dietary measures for a patient admitted with a diagnosis of acute pancreatitis?

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When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

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