NCLEX-PN

Category - Reduction of Risk

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A 35-year-old female client is diagnosed with peritonitis. Which of the following assessments warrants an immediate intervention?

Pulse rate of 120, blood pressure of 90/60
Temperature of 100^OF
Decreased bowel sounds
Shallow respirations

Explanation

Answer: A - Tachycardia and hypotension are initial signs of shock. Immediate attention should be given to hydrate the client and correct electrolyte imbalances, with physician order. Fever is the body’s response to infection and fluid loss. Decreased bowel sounds may be due to paralytic ileus and abdominal distention. Shallow respirations may result from upward displacement of the diaphragm due to ascites.

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