Client is alert and oriented and reports not feeling well for a few days. Client
is on continuous ambulatory peritoneal dialysis (CAPD) and reports dialysate
appeared cloudy this morning.
Reports abdominal pain as 4 on a scale of 0 to 10.
Bowel sounds active in all quadrants.
Peritoneal dialysis access site red, warm to touch, with a small amount of
purulent drainage noted on dressing.1300:
Client is lying in bed with the knees flexed, guarding the abdomen. Abdomen
is slightly distended, hypoactive bowel sounds. Client reports nausea.
Reports pain as 6 on a scale of 0 to 10. Provider notified and updated with
client condition and diagnostic results.: The client is experiencing
,manifestations of peritonitis
due to
x-ray results
.
2. NGN
Client admitted to medical-surgical unit from PACU. Client reports
incisional pain as 2 on a scale of 0 to 10. Client appears restless and
frequently asks for water. Bilateral lower extremities cool with +1 pedal
pulses. Urine output is 40 mL for the past 2 hr. Moderate amount of bright
red drainage noted on surgical incision dressing.: Insert a large-gauge IV.
Initiate a fluid challenge.
Hypovolemia
Urine output
,Blood
pressure
3. A nurse is caring for a client who has a potassium level of 3 mEq/L. Which
of the following assessment findings should the nurse expect?: Hypoactive
Bowel Sounds
4. NGN
0900:
Client presents with abdominal pain in the upper left quadrant for the past 2
days. States pain became worse this morning and is radiating to the back.
Rates pain as 8 on a scale of 0 to 10.
Hypoactive bowel sounds; reports nausea, no vomiting; client is passing
flatus.
, Febrile, oriented to person, place, and
time. Tachypnea with diminished breath
sounds. Sinus tachycardia.
Client voids 300 mL of clear, amber
urine. 0930:
Client vomited 100 mL brown liquid.: The client is experiencing
manifestations of pancreatitis
as evidenced by the
amylase and lipase
.
5. 0530:
Client is awake and alert.
Arteriovenous fistula (AVF) to right forearm with thrill palpated and
auscultat- ed for bruit. Lung sounds clear upon auscultation; client denies
shortness of breath. No peripheral edema noted; capillary refill is less than 3
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