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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Asking the client to describe their pain allows the nurse to gather subjective information directly from the client, which can provide valuable insight into the quality, intensity, location, and duration of the pain.
A. This option focuses on pain management rather than pain assessment. While identifying effective pain relief measures is important, it does not directly address the need to assess the quality of the client's pain.
B. While numeric pain scales can be useful for quantifying pain intensity, they do not capture the quality or characteristics of the pain.
D. Observing body language and movement can provide valuable information about the client's pain experience, such as grimacing, guarding, or difficulty moving. However, this approach primarily assesses pain behaviors rather than the quality of the pain itself.
Correct Answer is B
Explanation
B. Postural drainage involves placing the client in various positions to help drain secretions from different lobes of the lungs. There are typically five standard positions: head-down, head-up, on the side with the affected lung uppermost, on the side with the affected lung lowermost, and lying prone.
A. Performing postural drainage immediately after meals is not recommended because it can increase the risk of vomiting or aspiration, especially in individuals with chronic obstructive pulmonary disease (COPD) who may already have compromised lung function.
C. In postural drainage, the client is typically instructed to breathe deeply and slowly to maximize the effectiveness of the technique.
D. While ABGs may be necessary for monitoring respiratory status in clients with COPD, they are not specifically required prior to performing postural drainage.
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