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: Ascites, fluid accumulation in the peritoneal cavity, is a common complication of liver cirrhosis due to portal hypertension and hypoalbuminemia. It increases infection risk and discomfort, making it the priority to monitor, as early detection guides diuretic therapy and paracentesis.

Choice B reason: Peripheral neuropathy is not a primary cirrhosis complication, though it may occur in alcoholic liver disease. Ascites is more common, resulting from portal hypertension, making it the priority to monitor, as it directly reflects liver dysfunction and requires urgent management.

Choice C reason: Pulmonary edema is associated with heart failure, not cirrhosis. Ascites is a hallmark of cirrhosis, caused by portal hypertension and low albumin, making it the priority complication to monitor, as it indicates worsening liver function and requires immediate intervention.

Choice D reason: Kidney stones are unrelated to cirrhosis, which primarily causes ascites due to portal hypertension. Monitoring ascites is critical, as it reflects liver decompensation, increasing risks like spontaneous bacterial peritonitis, making it the priority over unrelated renal conditions.

A. Increase carbohydrate intake at meals B. Review the client’s medication regimen C. Monitor blood glucose every hour D. Encourage high-protein snacks

Correct Answer is B

Explanation

Choice A reason: Increasing carbohydrate intake may prevent hypoglycemia but does not address the root cause, such as excessive insulin or oral hypoglycemic agents. Reviewing medications identifies dosing issues, ensuring safer management of type 2 diabetes, making it the priority over dietary changes.

Choice B reason: Reviewing the medication regimen is critical, as hypoglycemia in type 2 diabetes often results from excessive insulin or sulfonylureas. Adjusting doses or timing with a provider prevents recurrent episodes, addressing the primary cause and ensuring safe glycemic control, making it the priority action.

Choice C reason: Monitoring blood glucose hourly is reactive and impractical long-term. It confirms hypoglycemia but does not prevent it. Reviewing medications addresses the cause, such as inappropriate dosing, making it more effective for managing recurrent hypoglycemia in type 2 diabetes.

Choice D reason: High-protein snacks stabilize blood glucose but are secondary to addressing medication-related hypoglycemia. Excessive insulin or oral agents are likely causes, so reviewing the regimen is prioritized to correct dosing, preventing recurrent episodes more effectively than dietary adjustments alone.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of liver cirrhosis. Which complication should the nurse monitor for?

Correct Answer is A

Explanation

The nurse is caring for a client with type 2 diabetes mellitus who reports frequent episodes of hypoglycemia. Which action should the nurse prioritize?

Correct Answer is B

Explanation

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