ATI NUR 213 Midpoint Assessment

Correct Answers:

B. Rigid abdomen

C. Inability to pass stools

E. Decreased urinary output

Explanation of Correct Answers:

B. Rigid abdomen

A rigid abdomen is a hallmark sign of peritonitis, indicating peritoneal inflammation and muscular guarding. This rigidity is due to the irritation of the peritoneal lining, which causes the abdominal muscles to involuntarily contract in an effort to protect the inflamed organs. It is often accompanied by severe pain and tenderness, and it is a red flag for a potentially life-threatening abdominal emergency requiring prompt medical intervention.

C. Inability to pass stools

Peritonitis can lead to paralytic ileus, a condition where the intestines stop moving normally. As a result, patients often experience a complete cessation of bowel movements and gas passage. This is a significant finding that reflects the severity of abdominal inflammation and the disruption of normal gastrointestinal motility, requiring urgent evaluation and management.

E. Decreased urinary output

Decreased urinary output (oliguria) may occur in peritonitis as a consequence of fluid shifting into the abdominal cavity (third spacing) and systemic inflammatory response syndrome (SIRS), leading to reduced renal perfusion. This drop in kidney function is a serious complication, potentially indicative of progressing sepsis or hypovolemia, and should be addressed immediately.

Why the Other Options Are Wrong:

A. Hyperactive bowel sounds

This is incorrect because peritonitis typically causes a decrease in bowel activity rather than an increase. In the early stages of inflammation, bowel sounds may be normal or slightly increased, but as the condition progresses and the intestines become paralyzed (ileus), bowel sounds diminish or are absent. Therefore, hyperactive bowel sounds are not characteristic of established peritonitis.

D. Frequent bowel movements

This is incorrect because frequent bowel movements are not associated with peritonitis. Instead, due to inflammation and ileus, patients often experience reduced or absent bowel function. Diarrhea might be seen in cases of infectious colitis or gastroenteritis, but not in peritonitis, which is characterized by halted bowel activity, not increased motility.

Correct Answer:

Turn the patient completely to one side

Explanation:

When a postoperative patient begins to retch or vomit, the immediate concern is airway protection and aspiration prevention. Turning the patient completely to one side—known as the lateral recovery position—helps prevent aspiration by allowing emesis or secretions to drain from the mouth rather than be aspirated into the lungs. This is especially critical in a postoperative patient who may still be under the influence of anesthesia or opioids, both of which can blunt protective airway reflexes.

Why the Other Options Are Wrong:

Administer a dose of IV analgesic:

This is inappropriate in response to retching unless pain is the primary trigger and has already been assessed. Moreover, opioid analgesics can worsen nausea, and administering them without addressing the emesis could exacerbate the problem and lead to aspiration.

Apply a cool cloth to the patient's forehead:

This is a comfort measure and does not address the primary concern of protecting the airway during retching or potential vomiting. It may provide relief after the nausea has been managed, but it does nothing to prevent the complications associated with vomiting.

Offer the patient a small amount of ice chips:

Offering anything by mouth is contraindicated during active retching or vomiting, especially in a postoperative patient who is at high risk for aspiration. The priority is to prevent choking and secure the airway, not to soothe the nausea with oral fluids.

Turning the patient to one side is an evidence-based, immediate nursing intervention to reduce aspiration risk, especially when nausea or vomiting occurs in the postoperative setting.

Correct Answer: Maintaining a patent airway

Explanation:

The highest nursing priority for a patient just transferred to the PACU from the operating room is maintaining a patent airway. Postoperative patients are at risk for airway compromise due to residual anesthesia effects, which can cause sedation, reduced respiratory drive, or obstruction from the tongue or secretions. Ensuring airway patency is critical to prevent hypoxia and support oxygenation, aligning with the ABCs (Airway, Breathing, Circulation) of emergency and postoperative care. The nurse must assess respiratory status, position the patient appropriately, and intervene promptly if signs of obstruction or respiratory depression occur, as this is essential for patient safety during the immediate recovery phase.

Why Other Options Are Wrong:

Assessing for hemorrhage. While assessing for hemorrhage is important, it is not the highest priority upon arrival in the PACU. Airway patency takes precedence, as respiratory compromise can lead to rapid decompensation and death within minutes, whereas hemorrhage, though serious, typically presents with signs like hypotension or tachycardia that can be addressed after ensuring airway and breathing. This option is a secondary concern compared to the immediate need to secure the airway. Focusing on hemorrhage first could delay critical interventions for respiratory issues.

Managing the patients pain. Pain management is a key aspect of postoperative care, but it is not the highest priority immediately upon PACU arrival. Uncontrolled pain can contribute to agitation or increased vital signs, but it does not pose the same immediate life-threatening risk as airway compromise. Pain assessment and treatment typically follow stabilization of airway, breathing, and circulation. This option is less urgent than ensuring a patent airway in the critical early recovery period.

Assessing vital signs every 30 minutes. Assessing vital signs is important for monitoring postoperative status, but the frequency of every 30 minutes is too infrequent for the PACU, where vital signs are typically checked every 5–15 minutes initially due to the patient’s unstable condition. More critically, maintaining a patent airway supersedes routine vital sign checks, as airway obstruction can cause rapid deterioration before the next scheduled assessment. This option does not address the immediate, life-saving priority of airway management.

Correct Answer:

B. Start infusion of Norepinephrine 4 mg/250 mL D5W

Explanation:

Start infusion of Norepinephrine 4 mg/250 mL D5W is correct because norepinephrine is the first-line vasopressor recommended for patients in septic shock who remain hypotensive despite adequate fluid resuscitation. Septic shock causes profound vasodilation and capillary leakage, which results in severe hypotension. Norepinephrine works primarily by stimulating alpha-adrenergic receptors, causing vasoconstriction and thereby increasing systemic vascular resistance and blood pressure. It is the vasopressor of choice according to the Surviving Sepsis Campaign guidelines.

Why the Other Options Are Wrong:

Start infusion of Nitroprusside 100 mg/250 mL D5W is incorrect because nitroprusside is a potent vasodilator used to treat hypertensive emergencies, not hypotension. Administering it to a patient in septic shock with an already low blood pressure would further lower systemic vascular resistance and worsen perfusion, leading to organ failure.

Start infusion of Nitroglycerin 50 mg/250 mL 0.9% NS is incorrect because nitroglycerin is also a vasodilator. It is typically used to reduce preload and treat conditions like angina or pulmonary edema due to heart failure. It would be contraindicated in a hypotensive patient in septic shock, as it could exacerbate the hypotension and decrease organ perfusion.

Start infusion of Dobutamine 500 mg/250 mL D5W is incorrect because while dobutamine is a positive inotrope used to improve cardiac output in patients with myocardial dysfunction, it is not the first-line agent in septic shock when hypotension is the primary issue. Dobutamine may be added if there is persistent hypoperfusion despite adequate mean arterial pressure, but it is not the initial vasopressor of choice for low blood pressure alone.

Correct Answer:

Assess vital signs and level of consciousness.

Explanation:

The presence of a pacing spike without a subsequent QRS complex on the ECG indicates failure to capture, meaning the pacemaker is sending electrical impulses, but the heart is not responding with ventricular contraction. This can lead to inadequate cardiac output and compromised perfusion. The nurse’s immediate priority is to assess the client's vital signs and level of consciousness to determine the impact of the ineffective pacing on systemic perfusion and neurological status. This assessment guides urgent interventions and informs the healthcare provider for potential adjustments to the pacemaker settings or other emergency measures.

Why Other Options Are Wrong:

Administer intravenous diltiazem (Cardizem).

Diltiazem is a calcium channel blocker used to slow ventricular rate in atrial fibrillation or supraventricular tachycardia. It is contraindicated in bradycardia and pacemaker failure because it can further depress cardiac conduction and worsen bradycardia or heart block.

Administer sublingual nitroglycerin.

Nitroglycerin is used to relieve ischemic chest pain by dilating coronary arteries. It is inappropriate in this situation because the client’s issue is inadequate ventricular contraction due to pacemaker failure, not ischemic chest pain.

Assess capillary refill and temperature.

While assessing peripheral perfusion like capillary refill and temperature is important, it is secondary to evaluating vital signs and neurological status. The systemic effects of pacemaker failure are better reflected in heart rate, blood pressure, and level of consciousness, which provide immediate information about cardiovascular stability.

Correct Answers:

b. Hypertension

c. Obesity

d. Smoking

e. Stress

Explanation:

Coronary artery disease (CAD) develops when the major blood vessels that supply the heart become damaged or diseased, typically due to a buildup of plaque. While certain risk factors like genetics and age cannot be changed, modifiable risk factors are those that individuals can take action on to significantly reduce their risk.

Hypertension increases the force of blood against arterial walls, causing damage and promoting plaque formation. When well-managed through medication, diet, exercise, and stress reduction, the risk of CAD is substantially lowered.

Obesity, particularly central (abdominal) obesity, contributes to a cascade of metabolic disturbances including hypertension, dyslipidemia, and insulin resistance—all of which accelerate atherosclerosis and raise CAD risk. Weight reduction improves nearly all these parameters.

Smoking introduces toxins that damage the endothelium (inner lining of blood vessels), promote atherogenesis, increase heart rate and blood pressure, and reduce oxygen delivery. Smoking cessation has an immediate and profound impact on lowering cardiovascular risk.

Stress, especially chronic and unmanaged, can contribute to poor lifestyle behaviors (e.g., overeating, inactivity, smoking) and may independently promote inflammation and vascular dysfunction. Effective stress management supports cardiovascular health.

Why "a. Age" is Incorrect:

Age is considered a non-modifiable risk factor. The risk for CAD increases with age due to cumulative vascular wear and the progressive nature of atherosclerosis. While older adults can still make impactful lifestyle changes, the passage of time itself is not subject to modification.

Summary:

Hypertension, obesity, smoking, and stress are modifiable risk factors for CAD. They are amenable to lifestyle changes and medical interventions, making them critical targets in both prevention and management strategies. In contrast, age is unchangeable and thus classified as a non-modifiable risk factor.

Correct Answer:

Treat the possible airway obstruction by tilting the head back and pushing forward on the angle of the lower jaw.

Explanation:

The patient’s blue, dusky skin and absence of breathing indicate a critical airway emergency, likely due to obstruction or respiratory arrest, requiring immediate intervention. The priority action is to open the airway using the head-tilt, chin-lift maneuver or jaw-thrust maneuver (pushing forward on the angle of the lower jaw), as these techniques can quickly relieve an obstruction caused by the tongue or soft tissue collapse, common in postoperative patients under residual anesthesia effects. This intervention aligns with the ABCs (Airway, Breathing, Circulation) of emergency care, prioritizing airway patency to restore oxygenation. If the airway remains obstructed, further steps like bag-valve-mask ventilation or advanced airway management may be needed, but opening the airway is the first critical step.

Why Other Options Are Wrong:

Check the patient’s oxygen saturation level, continue to monitor for apnea, and perform a focused assessment. Monitoring oxygen saturation or continuing to assess without immediate intervention delays critical action in a patient who is not breathing. The blue, dusky skin indicates severe hypoxia, and time spent on monitoring or assessment could worsen outcomes, as brain damage can occur within minutes of apnea. While a focused assessment may follow after securing the airway and breathing, it is not the priority when the patient is not breathing. This option fails to address the urgent need to restore airway patency and oxygenation.

Assess the arterial pulses, and place the patient in the Trendelenburg position.

Assessing arterial pulses is part of the circulation check, which comes after ensuring airway and breathing in the ABC protocol. The patient’s primary issue is the absence of breathing, not a circulatory problem, and placing the patient in the Trendelenburg position (head lower than feet) is inappropriate, as it may worsen airway obstruction or impair ventilation. This option misprioritizes circulation over airway management and introduces an irrelevant intervention for this scenario. Immediate airway management takes precedence over pulse checks or positioning changes.

Reintubate the patient.

Reintubation may be necessary if initial airway maneuvers fail, but it is not the first step, as it requires advanced skills, equipment, and time, which could delay oxygenation in an apneic patient. Non-invasive techniques like the jaw-thrust or head-tilt, chin-lift should be attempted first to quickly restore airway patency, especially in the PACU where residual anesthesia effects may cause temporary obstruction. Reintubation also carries risks like esophageal intubation or delayed ventilation, making it a secondary option. This choice skips critical initial steps in managing an acute airway emergency.

Correct Answer: A. Assess for symptoms of left-sided heart failure.

Explanation:

An S3 gallop is an abnormal heart sound that occurs after S2 during early diastole and is often a sign of left-sided heart failure due to fluid overload and decreased ventricular compliance. It is sometimes called a ventricular gallop and is most commonly heard in conditions where there is increased left ventricular filling pressure, such as heart failure, volume overload, or severe mitral regurgitation.

Why the Other Options Are Incorrect:

B. Document this as a normal finding. – An S3 gallop is not a normal finding in adults. It may be normal in children, young adults, and pregnant women due to high cardiac output, but in older adults, it suggests heart failure or volume overload.

C. Call the health care provider immediately. – While an S3 gallop is an important clinical finding, it is not always an emergency. The nurse should first complete an assessment for other signs of heart failure, such as dyspnea, crackles in the lungs, edema, and jugular venous distension (JVD), before escalating care.

D. Transfer the client to the intensive care unit. – An S3 gallop alone does not warrant an ICU transfer unless the client is unstable, experiencing severe respiratory distress, hypotension, or cardiogenic shock.

Summary:

An S3 gallop is often an early indicator of left-sided heart failure due to fluid overload and poor ventricular compliance. The next best action is to assess for other signs of heart failure, including pulmonary congestion, dyspnea, orthopnea, and peripheral edema, before notifying the provider or taking further action.

Correct Answer:

c. "It increases the force of the heart's contractions."

Explanation:

Inotropic agents primarily function to alter the strength or force of the heart's contractions. Positive inotropes—such as dobutamine, dopamine, milrinone, and digoxin—are commonly used in the treatment of heart failure, cardiogenic shock, or post-MI low cardiac output states to increase myocardial contractility. By doing so, these agents improve cardiac output and systemic perfusion, which are crucial in patients with impaired cardiac function. The increase in contractile strength allows the failing heart to pump more blood effectively, alleviating symptoms and reducing end-organ hypoperfusion.

Why the Other Options Are Incorrect:

"It constricts vessels, improving blood flow."

This is incorrect because vasoconstriction alone does not improve blood flow; in fact, it may increase afterload (the resistance the heart must pump against), which can worsen cardiac performance in some patients. While high doses of dopamine can cause vasoconstriction by stimulating alpha-adrenergic receptors, this is not the primary mechanism of inotropic action and not a universal feature of all inotropes.

"It dilates vessels, which lessens the work of the heart."

Although some inotropes like milrinone have vasodilatory (afterload-reducing) properties, vasodilation is not the defining action of inotropic agents. The primary therapeutic intent with inotropes is to strengthen cardiac contraction, not to modulate vascular tone, although this can be a helpful secondary effect in certain drugs.

"It slows the heart rate down for better filling."

Slowing the heart rate is characteristic of negative chronotropic agents (e.g., beta-blockers, digoxin at low doses), not inotropes specifically. Some inotropes may secondarily affect heart rate (e.g., digoxin may slow AV conduction), but this is not their main therapeutic purpose. Inotropes are aimed at increasing contractile strength, not at rate control.

Summary:

Inotropic agents are used to increase the strength of the heart's contractions, improving cardiac output and tissue perfusion in conditions like heart failure or cardiogenic shock. This positive inotropic effect is their defining and most clinically significant mechanism of action.