A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?

Administer an antacid as prescribed

Assess the characteristics of the pain

Check for recent NSAID use

Obtain a stool sample for occult blood

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering an antacid relieves epigastric pain but is premature without assessing pain characteristics. Pain in peptic ulcer disease may indicate complications like perforation, requiring urgent evaluation. Assessment guides whether antacids or other interventions are appropriate, prioritizing patient safety.

Choice B reason: Assessing pain characteristics (e.g., location, intensity, radiation) is the first step, as epigastric pain in peptic ulcer disease may signal complications like bleeding or perforation. This data guides interventions, ensuring timely management of potentially life-threatening conditions, making it the priority action.

Choice C reason: Checking NSAID use identifies ulcer triggers but is secondary to pain assessment. Pain characteristics determine urgency, as severe or radiating pain may indicate perforation, requiring immediate action. Assessment provides critical data before investigating contributing factors like medication history.

Choice D reason: Obtaining a stool sample for occult blood detects gastrointestinal bleeding but is not the first step. Assessing pain characteristics identifies urgent complications like perforation, guiding whether diagnostic tests or interventions are needed, making pain assessment the initial priority.

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Correct Answer is A

Explanation

Choice A reason: Monitoring daily urine output assesses kidney function and fluid balance, as urine volume reflects hydration and electrolyte homeostasis. Inadequate output signals dehydration or renal issues, allowing timely intervention to maintain fluid and electrolyte balance, making it the most effective nursing action.

Choice B reason: Salt tablets after exercise replace sodium lost in sweat but are not a universal intervention for fluid and electrolyte balance. They risk hypernatremia if overused. Monitoring urine output is more comprehensive, as it directly evaluates fluid status across various clinical scenarios.

Choice C reason: Reviewing food labels for sodium content helps manage dietary intake but is indirect and patient-dependent. Urine output monitoring provides objective data on fluid and electrolyte status, enabling timely adjustments in therapy, making it a more immediate and reliable intervention.

Choice D reason: Drinking water when thirsty supports hydration but relies on subjective thirst, which may be impaired in certain conditions. Monitoring urine output objectively assesses fluid balance, detecting imbalances early, making it a more proactive and precise intervention than thirst-driven hydration.

A. Hemoglobin B. Glucose C. Total protein D. Sodium

Correct Answer is A

Explanation

Choice A reason: Diclofenac, an NSAID, can cause gastrointestinal bleeding, leading to anemia. Pale appearance and fatigue suggest blood loss. Reviewing hemoglobin levels is critical to confirm anemia, as low hemoglobin impairs oxygen delivery, exacerbating fatigue and requiring immediate intervention to address potential bleeding.

Choice B reason: Glucose levels are unrelated to diclofenac’s common side effects. Fatigue may occur in hypoglycemia, but diclofenac does not typically affect glucose metabolism. Pale appearance and fatigue are more indicative of anemia from NSAID-related bleeding, making hemoglobin a more urgent lab value to review.

Choice C reason: Total protein levels reflect nutritional status or liver function but are not directly linked to diclofenac’s side effects. Fatigue and pallor suggest anemia from gastrointestinal bleeding, a known NSAID risk. Hemoglobin is more critical to assess, as it directly correlates with the client’s symptoms.

Choice D reason: Sodium levels influence fluid balance but are not typically altered by diclofenac. Fatigue and pallor point to anemia from potential bleeding, not electrolyte imbalance. Hemoglobin review is prioritized, as diclofenac’s gastrointestinal side effects are more likely to cause blood loss than sodium disturbances.

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A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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