A client was admitted in the hospital with peptic ulcer disease tells the nurse about having black tarry stools. Which of the following is the most appropriate nursing action?

Instruct the client to increase fluid intake.

Notify the health care provider.

Advise the client to take iron rich foods.

Document the findings.

Answer and Explanation

The Correct Answer is B

Choice A Reason: Instructing the client to increase fluid intake is not the most appropriate nursing action, as it does not address the cause or severity of the bleeding.

Choice B Reason: Notifying the health care provider is the most appropriate nursing action, as it indicates that the client may have a bleeding ulcer that requires immediate evaluation and treatment.

Choice C Reason: Advising the client to take iron rich foods is not the most appropriate nursing action, as it does not prevent or correct anemia or bleeding.

Choice D Reason: Documenting the findings is not the most appropriate nursing action, as it does not initiate any intervention or outcome.

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Correct Answer is C

Explanation

Choice A Reason: Assisting the RN to prepare an IV insulin infusion is not the first action that the nurse should take, as it may not be appropriate for the client's condition without knowing the blood glucose level.

Choice B Reason: Giving the client 4 oz of orange juice is not the first action that the nurse should take, as it may worsen the client's condition if the blood glucose level is high.

Choice C Reason: Checking the client's capillary blood glucose is the first action that the nurse should take, as it helps to determine if the client has hyperglycemia or hypoglycemia and guides the appropriate intervention.

Choice D Reason: Assisting the RN to administer 50% dextrose is not the first action that the nurse should take, as it may be harmful for the client if the blood glucose level is high.

A. Increased pain B. Continuous swallowing C. Poor fluid intake D. Drooling

Correct Answer is B

Explanation

Choice A Reason: Increased pain is not a specific sign of hemorrhage, but it may indicate inflammation, infection, or nerve damage.

Choice B Reason: Continuous swallowing is a sign of hemorrhage, as it indicates that blood is accumulating in the throat or esophagus and stimulating the swallowing reflex.

Choice C Reason: Poor fluid intake is not a sign of hemorrhage, but it may indicate difficulty swallowing, nausea, or dehydration.

Choice D Reason: Drooling is not a sign of hemorrhage, but it may indicate impaired oral control, salivary gland damage, or infection.

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A client was admitted in the hospital with peptic ulcer disease tells the nurse about having black tarry stools. Which of the following is the most appropriate nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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