A client presents to the emergency department vomiting dark brown emesis and in severe abdominal pain. The client reports to the nurse of recently being diagnosed with adenocarcinoma of the small intestine. After auscultating bowel sounds and obtaining vital signs, which prescription should the nurse implement next?
Insert a nasogastric tube (NGT) and attach to low intermittent suction.
Place an indwelling urinary catheter and attach a bedside drainage unit.
Send the client to x-ray for a flat plate of the abdomen.
Give a prescribed analgesic for temperature above 101°F (38.3°C).
The Correct Answer is A
A. Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction would be appropriate in this situation. Dark brown emesis could indicate gastrointestinal bleeding, which may require gastric decompression to prevent further vomiting and assess the volume and characteristics of the gastric contents.
B. Placing an indwelling urinary catheter and attaching a bedside drainage unit is not the priority intervention in this scenario.
C. Sending the client to x-ray for a flat plate of the abdomen may provide diagnostic information, but it is not the most immediate intervention needed in this situation.
D. Giving a prescribed analgesic for a temperature above 101°F (38.3°C) is not the priority intervention in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Vancomycin is primarily excreted by the kidneys, and monitoring serum creatinine levels helps assess renal function. Impaired renal function can affect vancomycin clearance and increase the risk of toxicity.
A. Measuring oxygen saturation is not directly related to the administration of vancomycin for Clostridium difficile infection.
B. Assessing body temperature may not be the most pertinent action before administering vancomycin for Clostridium difficile infection.
C. Auscultating bowel sounds is also not directly related to the administration of vancomycin for Clostridium difficile infection.
Correct Answer is A
Explanation
A. Tiotropium is commonly delivered via a handihaler device for inhalation. Using the medication every day is consistent with the recommended dosing regimen for managing chronic obstructive pulmonary disease (COPD) symptoms.
B. While it's important for clients with COPD to have access to a rescue inhaler for sudden shortness of breath, it's also crucial for them to understand the specific instructions for using each medication.
C. Tiotropium is a long-acting bronchodilator that helps relax the airway muscles. It does not have direct effect on the thickness of mucus secretions.
D. While tiotropium can help prevent exacerbations and reduce the frequency of sudden shortness of breath, it is not typically used as a rescue inhaler for acute symptom relief.
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