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W125 Med Surgical 2 Benchmark Lippincott Proctored Exam
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Showing 10 questions, Sign in for moreClient post Roux-en-Y surgery day 2. Client started a clear liquid diet yesterday Client reports sudden onset of epigastric pain rated 8/10. Pain on last assessment 3/10. Hyperactive bowel sounds noted. Rigid boardlike abdomen on assessment. No bowel movement yet post-op.
- Blood pressure: 98/32
- Respiratory rate: 18
- Heart rate: 110
- Temperature: 101° F 38.3oC
- Spo2: 96% on RA
- CBC: WBC 18,500/mm³ (5,000–10,000/mm³)
- Lactate: 3.2 mmol/L (0.5–2.2 mmol/L)
- Abdominal X-ray: dilated bowel loops with free air under diaphragm
The nurse cares for a postoperative client.
Review the electronic health record. Complete the diagram by dragging from the choices below to specify what 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
Explanation
Brief introduction:
Recognizing postoperative complications following a Roux-en-Y gastric bypass such as peritonitis is crucial. Peritonitis is an acute, life-threatening inflammation of the peritoneum often caused by gastrointestinal perforation, as suggested by free air under the diaphragm on abdominal X-ray. Clinical findings such as rigid “board-like” abdomen, severe worsening abdominal pain, fever, leukocytosis, and elevated lactate indicate systemic inflammatory response and possible sepsis. Prompt recognition and urgent intervention are essential to prevent rapid deterioration.
Rationale for correct choices:
• The presence of sudden severe abdominal pain, rigid board-like abdomen, fever, leukocytosis, elevated lactate, and free air under the diaphragm strongly indicates gastrointestinal perforation leading to peritonitis. Postoperative Roux-en-Y patients are at risk for anastomotic leak, which can release gastric contents into the peritoneal cavity. This causes widespread inflammation and systemic infection. These findings are classic for acute peritonitis rather than routine postoperative changes.
• Inserting a nasogastric tube helps decompress the gastrointestinal tract, reduce gastric distention, and limit further leakage of gastric contents into the peritoneal cavity. This is a critical supportive intervention in suspected bowel perforation or peritonitis. It also helps prevent vomiting and aspiration, which are high risks in this unstable client. Gastric decompression is a priority stabilizing measure.
• Broad-spectrum antibiotics are essential because peritonitis is typically caused by polymicrobial infection from gastrointestinal flora. Early administration helps control systemic infection and reduce the risk of sepsis and septic shock. The client already shows signs of systemic inflammatory response, including fever, tachycardia, and elevated WBC. Prompt antibiotic therapy is life-saving in this condition.
• Nausea and vomiting are common manifestations of peritonitis due to severe abdominal inflammation and bowel irritation. Monitoring these symptoms helps evaluate worsening obstruction, infection severity, and risk of aspiration. In postoperative abdominal complications, increasing nausea/vomiting can indicate deterioration. It is a key clinical indicator of progression.
• Elevated WBC count reflects ongoing infection and inflammatory response in peritonitis. In this case, a WBC of 18,500/mm³ indicates significant systemic infection. Monitoring trends helps evaluate response to antibiotics and worsening sepsis risk. It is a critical laboratory marker of disease severity and progression.
Rationale for incorrect options:
• Although abdominal pain and no bowel movement could suggest obstruction, the presence of free air under the diaphragm and rigid board-like abdomen is not consistent with simple obstruction. SBO does not typically cause pneumoperitoneum or severe systemic infection with elevated lactate.
• Appendicitis is unlikely in a postoperative Roux-en-Y patient with diffuse rigid abdomen and free air under the diaphragm. Appendicitis typically presents with localized right lower quadrant pain (McBurney’s point) rather than generalized peritonitis findings. The severity and imaging findings here indicate a more advanced intra-abdominal catastrophe.
• Severe abdominal pain (8/10), rigid abdomen, fever, leukocytosis, and free air are not expected postoperative findings. Normal postoperative recovery would include gradually decreasing pain, soft abdomen, and stable vitals. These findings indicate a serious complication rather than normal healing.
• Advancing diet to full liquid is contraindicated because the client shows signs of acute abdominal perforation and peritonitis. Oral intake would worsen gastrointestinal leakage and increase peritoneal contamination. The priority is bowel rest, not feeding progression.
• Laxatives are inappropriate because the client’s condition is not constipation-related but due to suspected perforation. Increasing bowel motility could worsen leakage and abdominal irritation. This intervention could significantly increase risk of deterioration.
• Peritonitis is not transmitted via direct contact, so contact precautions are not indicated. Standard precautions are sufficient unless there is a specific infectious organism requiring isolation. The priority is emergency management, not isolation measures.
• Pain localized to McBurney’s point is classically associated with appendicitis, not generalized peritonitis. In this client, the pain is sudden, severe, and diffuse with a rigid “board-like” abdomen, which indicates widespread peritoneal inflammation rather than localized right lower quadrant irritation.
• Family member exposure is not a clinical indicator of the client’s physiologic status or disease progression. While infection control considerations may be relevant in contagious diseases, peritonitis is not transmitted through casual contact. Therefore, monitoring exposure of family members does not provide meaningful information about the severity or progression of the client’s intra-abdominal infection.
• Reverse peristaltic waves are more commonly associated with intestinal obstruction conditions such as bowel obstruction or severe gastric outlet obstruction. In this case, the diagnostic findings of free air under the diaphragm and rigid abdomen strongly indicate perforation with peritonitis rather than a motility disorder. Thus, it is not an appropriate parameter.
A client who performs peritoneal dialysis at home calls the nurse at the dialysis clinic to report pain and tenderness in the abdomen and vomiting since yesterday. Which assessment question is most important for the nurse to ask the client?
The nurse cares for a client with second and third-degree burns covering 40% of their total body surface area (TBSA). When performing a dressing change, which action should the nurse perform?
A client's stump is healing after a below-the-knee amputation, and the client asks the nurse detailed questions about the healing process. What step does the nurse describe when teaching about the inflammatory phase of wound healing?
A client tests positive for vancomycin-resistant enterococci (VRE) in the gastrointestinal tract. Which nursing intervention is the priority in reducing the spread of the organism to other clients in the hospital?
A client was admitted to the neurological unit yesterday with new onset seizures. The seizures have been lasting for just over four minutes, and the nurse is concerned that they may start to last longer. Which prescription should the nurse ensure is written by the health care provider and always on hand for this client?
|
TIME |
BLOOD PRESSURE |
HEART RATE |
RESPIRATORY RATE |
TEMPERATURE |
SPO2
|
|
2300 |
130/84 |
90 |
18 |
98.8 °F 37.1° C |
98% RA |
|
2305 |
118/77 |
94 |
18 |
98.8 °F 37.1o C |
98% RA |
|
2310 |
89/56 |
110 |
22 |
98.8 °F 37.1o C |
96% RA |
|
TIME |
DIAGNOSTIC |
RESULT |
|
2300 |
12-Lead ECG |
ST elevation in leads V5 and V6 |
Medication:
Aspirin: Dosage: 81 mg Route: PO chew Frequency: 4 tabs NOW
Medication:
Nitroglycerin Dosage: 0.4 mg Route: sublingually 2300 Given. Frequency: every 5 minutes (2302 Given, 2307 Given) Parameters: up to 3 doses if SBP>90 mmHg
Medication:
Clopidogrel Dosage: 600 mg Route: PO Frequency: NOW 2305 Given
The nurse cares for a client with chest pain in the emergency department
Review the electronic health record. For each nurse action, click to specify if the action is indicated or not indicated to implement next.
Explanation
The patient presents with an acute coronary syndrome (ACS), specifically an evolving ST-elevation myocardial infarction (STEMI) involving the lateral leads (V5–V6), which suggests left ventricular ischemia. The client shows ECG evidence of myocardial injury with hemodynamic instability, including hypotension and tachycardia after nitroglycerin administration. Management priorities include restoring coronary perfusion, preventing lethal dysrhythmias, and preparing for emergent reperfusion therapy via percutaneous coronary intervention (PCI).
Rationale:
• Continuous cardiac monitoring: The client is experiencing an acute ST-elevation myocardial infarction with evolving hemodynamic instability. Continuous cardiac monitoring is essential to detect life-threatening dysrhythmias such as ventricular tachycardia or ventricular fibrillation, which are common complications during acute myocardial ischemia. Continuous monitoring is a critical safety intervention that allows immediate recognition and treatment of rhythm changes in real time.
• Administer a third dose of nitroglycerin: Nitroglycerin is contraindicated at this point because the client’s blood pressure has dropped to 89/56 mmHg. Further doses could worsen hypotension and reduce coronary perfusion, increasing risk of cardiogenic shock. According to protocol, nitroglycerin should be withheld when systolic BP is below 90 mmHg or when significant hypotension is present.
• Precautionary placement of defibrillator pads: STEMI significantly increases the risk of life-threatening ventricular dysrhythmias such as ventricular tachycardia or ventricular fibrillation. Defibrillator pads should be placed early to allow rapid response if the client deteriorates. This is a critical safety intervention in acute myocardial infarction with instability. It ensures immediate access to life-saving defibrillation if needed.
• Prepare for transcutaneous pacing: Transcutaneous pacing is used for symptomatic bradycardia or high-grade atrioventricular blocks, which are not present in this client. The ECG shows ST elevation without evidence of conduction block or bradyarrhythmia. The current issue is ischemia with hypotension, not bradycardia requiring pacing support.
• Prepare for transport to cardiac catheterization lab: The client is experiencing an acute STEMI, which requires immediate reperfusion therapy via percutaneous coronary intervention (PCI). Transport to the cardiac catheterization lab is the definitive priority to restore coronary blood flow and minimize myocardial damage. Time-sensitive intervention is critical (“time is muscle”). This is the most important definitive treatment step.
• Apply oxygen via nasal cannula: Although oxygen saturation is near normal, the client is experiencing acute myocardial ischemia with hypotension. Supplemental oxygen supports myocardial oxygen delivery and reduces ischemic burden during acute infarction. Oxygen therapy is indicated in unstable ACS patients, especially with hemodynamic changes. It supports tissue perfusion while awaiting definitive intervention.
A client visits the clinic with symptoms of a urinary tract infection (UTI), is diagnosed with a UTI, and is prescribed a course of antibiotic treatment. When the nurse teaches the client about the medication and preventing a subsequent UTI, which statements by the client indicate that the nurse will need to reinforce the teaching? Select all that apply
A client on a mechanical ventilator has experienced the loss of all brain function, confirmed by electroencephalogram (EEG). Before terminating life support, which action should the nurse prioritize considering the legal and ethical issues in end-of-life care?
The nurse is reviewing the client's current lab values. Which situation requires further evaluation?
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