A 55-year-old male patient presents to the emergency department with complaints of acute gastrointestinal (GI) bleeding. The patient reports passing black, tarry stools and experiencing dizziness and weakness. On physical examination, he is pale and diaphoretic.

Exhibits

Which of the following are the most appropriate initial nursing interventions for this patient? (Select all that apply)

Administer IV fluids

Prepare for possible blood transfusion

Monitor hemoglobin and hematocrit levels

Administer a proton pump inhibitor (PPI)

Administer oral iron supplements to address anemia

Answer and Explanation

Correct Answer : A,B,C,D

A. Administer IV fluids: The patient is hypotensive (blood pressure 88/54 mmHg) and tachycardic (heart rate 115 bpm), indicating possible hypovolemic shock due to blood loss. Administering IV fluids will help to stabilize blood pressure.

B. Prepare for possible blood transfusion: The patient's hemoglobin level is critically low (6.5 g/dL), indicating significant blood loss and severe anemia. Preparing for a blood transfusion is crucial to correct the anemia.

C. Monitor hemoglobin and hematocrit levels: Continuous monitoring of hemoglobin and hematocrit levels is vital to assess the severity of the patient's anemia and response to treatment, guiding further interventions.

D. Administer a proton pump inhibitor (PPI): PPIs can help reduce gastric acid secretion, which may help control bleeding from peptic ulcers, a common cause of upper GI bleeding.

E. Administer oral iron supplements to address anemia: Oral iron supplements are typically used for long-term management of iron deficiency anemia but are not effective for immediate correction of severe anemia, particularly in an acute setting with ongoing blood loss.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. I should eat large meals to reduce the frequency of acid reflux: Large meals can worsen GERD by increasing stomach pressure and acid production, leading to reflux. Small, frequent meals are recommended instead.

B. I should drink peppermint tea after meals to help with digestion: While peppermint may help with general digestion, it can relax the lower esophageal sphincter (LES), making GERD worse by allowing acid to reflux into the esophagus.

C. I should lie down immediately after eating to prevent heartburn: Lying down after meals increases the likelihood of acid reflux due to gravity, especially if the stomach is full, and should be avoided.

D. I should avoid eating meals at least 2-3 hours before bedtime. Avoiding meals 2-3 hours before bedtime helps reduce acid reflux by preventing the stomach from being full and producing excess acid when lying down.

A. Incontinence B. Gastrointestinal upset C. Urinary urgency D. Fever E. Flank pain

Correct Answer is ["B","C","D","E"]

Explanation

A. Incontinence: Incontinence is not a typical symptom of renal calculi. Pain, urgency, and difficulty urinating are more common.

B. Gastrointestinal upset: Nausea, vomiting, and gastrointestinal upset can occur as a result of renal colic due to the proximity of the kidneys to the gastrointestinal system.

C. Urinary urgency: Clients with renal calculi may experience urinary urgency due to irritation of the urinary tract.

D. Fever: Fever may indicate an infection related to the obstruction caused by the stone, such as pyelonephritis.

E. Flank pain: Flank pain, often severe and radiating to the lower abdomen or groin, is a classic symptom of renal calculi as the stone moves through the urinary tract.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A nurse is caring for a client admitted for renal calculus. Which of the following assessment findings should the nurse associate with renal calculi? (Select All that Apply.)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is assisting with teaching a client who is preoperative for a sigmoid colostomy. Which of the following statements should the nurse include?

A male patient is being discharged after hospitalization for a bleeding peptic ulcer. The nurse is providing discharge teaching on how to monitor for signs of recurrent bleeding. Which of the following statements by the patient indicates a need for further teaching?

A nurse is contributing to the plan of care for a client who has an intestinal obstruction and is receiving continuous gastrointestinal decompression using a nasogastric tube. Which of the following interventions should the nurse include in the plan of care?

A patient with suspected appendicitis is being prepared for surgery. Which of the following preoperative interventions should the nurse prioritize?

A female presents to the clinic with complaints of dysuria and increased urinary frequency. Which of the following findings on physical examination would most likely support a diagnosis of cystitis?

A nurse is reinforcing teaching about renal transplant with a newly licensed nurse. Which of the following clients should the nurse identify as having a contraindication for this procedure?

A female patient recently underwent a partial gastrectomy and is now presenting with symptoms of weakness, dizziness, and sweating, particularly after meals. Based on these symptoms, what is the most likely diagnosis?

A nurse is assessing an older adult client who has a urinary tract infection (UTI). Which of the following findings should the nurse identify as unique for this age group?