The nurse is caring for a client with acute pancreatitis. During the physical assessment, the nurse notes a grayish-blue discoloration of the client's flanks. Which is the nurse's priority action?
a. Prepare the client for emergency surgery.
b. Place the client in high Fowler's position.
c. Insert a nasogastric (NG) tube to low in-termittent suction.
d. Ensure that the client has a patent large-bore IV site.
D
Grayish-blue discoloration on the flanks (Turner's sign) indicates pancreatic enzyme leakage into the peritoneal cavity. This presents a risk of shock for the client, so IV access should be main-tained with at least one large-bore patent IV catheter. The client may or may not need surgery; usually a fetal position helps with pain, and having an NG tube would not take priority over IV access.
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The nurse is caring for a patient in end-stage renal failure and anemia. What is the cause of this patient's anemia?
A) Low serum iron levels B) Low erythropoietin levels C) Inadequate oxygenation of tissue D) Lack of B12 and folic acid intake
A client has gastroenteritis and frequent diarrhea. The nurse should assess the client for (Select all that apply)
a. bradycardia. b. decrease in blood pressure. c. decrease in urine output. d. temperature of 96° F. e. tenting of skin.
The nurse is preparing a preoperative plan of care for an older Hispanic client who is scheduled for a hysterectomy. The nurse recognizes the initial intervention for this client will be to:
1. Determine if the client understands English. If not, provide an interpreter. 2. Teach the client about turn, cough, and deep breathing. 3. Discuss the client's concerns about the surgery. 4. Explain that the client's pain will be controlled during the postoperative time frame.
A client, age 40, is admitted for a surgical biopsy of a suspicious lump in her left breast. When the nurse comes to take her to surgery, she is tearfully finishing a letter to her two children. She tells the nurse, "I want to leave this for my children in case anything goes wrong today." Which response by the nurse would be most therapeutic?
A. "In case anything goes wrong? What are your thoughts and feelings right now?" B. "I can understand that you're nervous, but this really is a minor procedure. You'll be back in your room before you know it." C. "Try to take a few deep breaths and relax. I have some medication that will help." D. "I'm sure your children know how much you love them. You'll be able to talk to them on the phone in a few hours."