Difficulty: Medium
Average Score: 80%
Simulated
Passage / Scenario
Vital SignsLaboratory Results
0800:
Client is admitted with a 3-day history of abdominal cramps and diarrhea of 4 to 5 liquid stools per day.
Client was taking amoxicillin/clavulanate 875 mg PO every 12 hr for 10 days for a respiratory tract infection. Antibiotics completed 7 days ago.
Bilateral breath sounds clear and present throughout.
Abdomen soft, distended with hyperactive bowel sounds audible in all 4 quadrants.
Stool is watery and contains mucous. Stool sent for culture.
The nurse should first address the client's ___ followed by the client's ___. (Options: Hgb level, Blood pressure, temperature, Hct level, abdominal findings, potassium level)
Correct answer
B,F
Rationale
Action to Take: B, F; Potential Condition: Hypovolemia; Parameter to Monitor: Blood Pressure, Potassium Level.
Rationale:
1. Blood pressure should be addressed first to assess perfusion status and hemodynamic stability.
2. Potassium level should be monitored next due to potential electrolyte imbalances in hypovolemia.
3. Hgb, Hct, and abdominal findings are important but secondary to addressing perfusion and electrolyte balance.
4. Temperature is not typically the initial concern in hypovolemia.
Rationale:
1. Blood pressure should be addressed first to assess perfusion status and hemodynamic stability.
2. Potassium level should be monitored next due to potential electrolyte imbalances in hypovolemia.
3. Hgb, Hct, and abdominal findings are important but secondary to addressing perfusion and electrolyte balance.
4. Temperature is not typically the initial concern in hypovolemia.