Difficulty: Medium
Average Score: 94%
Simulated
Passage / Scenario
0900:Client reports, "I'm bloated and my stomach hurts."
History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too. Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal and pain is worsened by eating.
Past Medical History: osteoarthritis
Social History: recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current Medications: Ibuprofen 800 mg three times daily PRN arthritis pain
General: client appears uncomfortable, diaphoretic
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear
A nurse assisting with the care of a client who is admitted to the medical-surgical unit.
The nurse is reviewing the client's laboratory findings and vital signs.
A nurse is assisting with the care of a client who is admitted to the medical-surgical unit. The nurse is reviewing the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.
Correct answer
B,C,F,G
Rationale
Stool results: A positive hemoccult test indicates gastrointestinal bleeding, likely due to a peptic ulcer. Heart rate: The tachycardia (118/min) suggests a compensatory response to hypovolemia. Blood pressure: Hypotension (90/50 mm Hg) is concerning for volume depletion. Hemoglobin and hematocrit: A hemoglobin of 9.1 g/dL and hematocrit of 27% indicate anemia. Current medications: Ibuprofen use is a major risk factor for gastrointestinal bleeding.