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 D
Explanation
A. Raising the voice volume to a shout can be startling for the client and may come across as aggressive or disrespectful.
B. Exaggerating nonverbal expressions might not effectively address the client's difficulty in hearing. While nonverbal communication is essential, especially for older adults with hearing impairments, exaggerating gestures may not necessarily improve communication clarity.
C. Speaking more slowly can help the client better understand what is being said without the nurse needing to shout, which might cause discomfort or further confusion.
D.Over-enunciating or exaggerating expressions can appear patronizing, and shouting can be distressing.
Correct Answer is B
Explanation
B. Pancreatitis is often associated with elevated serum amylase levels due to pancreatic inflammation. Therefore, this combination of clinical symptoms and laboratory findings is valuable in assessing the severity and confirming the diagnosis of pancreatitis.
A. While these are important clinical findings, they are not specific to pancreatitis and may not provide definitive information about the severity or cause of the condition.
C. Chronic constipation and serum gastrin levels are not typically associated with pancreatitis.
D. Serum Helicobacter pylori (H. pylori) antibody results and urine output amounts are not directly related to pancreatitis. H. pylori infection is associated with peptic ulcers and gastritis but not typically with pancreatitis.
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