Difficulty: Medium
Average Score: 84%
Simulated
Passage / Scenario
Nurses' Notes Day 1:1000:
ÔÇó A peripherally inserted central catheter (PICC) is inserted into left arm. Dressing dry and intact. Bilateral breath sounds clear and present throughout.
1200:
ÔÇó Parenteral nutrition started through PICC line infusing at 75 mL/hr. Day 3:
0800:
ÔÇó Client is lethargic and reports thirst and frequent urination. Bilateral breath sounds clear and present throughout
Diagnostic Results
Day 1:
1100:
ÔÇó Chest x-ray: PICC line in superior vena cava Day 3:
0800:
ÔÇó Hct 38% (37% to 47% )
ÔÇó Hgb 13 g/dL (12 g/dL to 16 g/dL)
ÔÇó WBC count 11,500/mm3 (5,000 to 10,000/mm3)
ÔÇó Casual glucose 300 mg/dL (less than 200 mg/dL)
ÔÇó Urine specific gravity 1.010 (1.005 to 1.030)
A nurse is reviewing the medical record of a client who has a paralytic ileus.Exhibits :Select words from the choices below to fill in each blank in the following sentence The findings in the client's medical record indicate ___ and ___.
Correct answer
A,B
Rationale
The correct answer is A,B. For a client with a paralytic ileus, hyperglycemia and infection are common findings. Hyperglycemia can occur due to stress response and decreased GI motility, while infection can result from bacterial overgrowth due to stasis. Pneumothorax and dehydration are not typically associated with paralytic ileus. Pneumothorax is a respiratory condition, and dehydration is more commonly linked to conditions causing fluid loss. Therefore, choices C and D are incorrect in this scenario.