The nurse is caring for a patient recovering from an endoscopic retrograde cholangiopancreatography (ERCP). Which findings should the nurse report to the charge nurse immediately? (Select all that apply.)
a. Nausea and vomiting
b. Onset of a fever and chills
c. Urine output 100 mL the last hour
d. Heart rate of 110 beats per minute
e. Increased right upper quadrant pain
ANS: A, B, D, E
After an ERCP the nurse should report nausea and vomiting, onset of fever and chills, rapid heart rate, and increased right upper quadrant pain which could indicate an infection or perforation of the pancreas. C. Urine output of 100 mL the last hour would not need to be reported to the charge nurse.
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