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 {"dropdown-group-1":"D","dropdown-group-2":"B"}
Explanation
Tachypnea refers to abnormally rapid breathing, characterized by an increased respiratory rate. In adults, tachypnea is typically defined as a respiratory rate above 20 breaths per minute at rest.
Tachycardia is a medical condition characterized by a rapid heart rate, typically above 100 beats per minute in adults at rest.
Eupnea refers to normal, unlabored breathing at a normal rate and depth. It is characterized by regular inhalations and exhalations without any signs of respiratory distress or abnormalities.
Hypothermia is a medical condition characterized by an abnormally low body temperature, typically below 95°F (35°C).
Bradycardia is a medical condition characterized by an abnormally slow heart rate, typically below 60 beats per minute in adults.
Hyperthermia is a medical condition characterized by an abnormally high body temperature, typically above 100.4°F (38°C).
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.