ATI Med Surg Woolery Final Exam | Nurselytic

Extract:

Nurses' Notes
0600:
Client was brought to the emergency department by her husband for complaints of abdominal pain 8/10 in all quadrants. Client is alert and oriented x4, states she has had a fever, nausea, and vomiting "off and on" for 2 days. Existing medical conditions include insulin-dependent type-2 diabetes, hypertension, and end-stage renal disease. Abdomen assessed, found to be rigid and distended. Rebound tenderness noted on palpation. Bowel sounds auscultated, hyperactive in all quadrants. Catheter present in abdominal wall, currently clamped. Client states "I do my own dialysis every day. Yesterday the effluent was cloudy. I haven't done an exchange yet today." STAT BMP and CBC have resulted. Physician notified. Awaiting orders.
Vital Signs
0600:
Temperature: 39.1°C (102.3°F)
Pulse rate: 110/min
Respiratory rate: 24/min
Blood pressure: 123/70 mmHg
Oxygen saturation: 95% room air

Laboratory results
0600:
BMP:
Creatinine: 3.8 mg/dL
Glucose: 180 mg/dL
Potassium: 5.4 mEq/L
Sodium: 134 mEq/L
BUN: 68 mg/dL CBC:
WBC: 15,000/mm3
RBC: 4.3 x 10/μL
Platelets: 250,000/μL
Hemoglobin: 12 g/dL
Hematocrit: 39%

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