A client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for an oral temperature of 103°F (39.4°C) and an IV infusion of normal saline is initiated at 250 ml/hour. Which assessment finding should the nurse report to the healthcare provider immediately?

Petechial haemorrhage under client's eyes.

Right lower abdomen rebound tenderness.

Severe headache with photosensitivity.

Dark green coloured emesis.

Answer and Explanation

The Correct Answer is B

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

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Correct Answer is A

Explanation

Choice A reason: Keeping the client NPO (nothing by mouth) is essential to prevent further irritation of the gastrointestinal tract and to allow the postoperative stricture to heal. When the client is experiencing significant symptoms like nausea and vomiting, keeping them NPO can help manage these symptoms and prevent complications such as aspiration or worsening of the stricture.

Choice B reason: Administering daily vitamin supplements may be necessary for long-term nutritional management, especially after bariatric surgery. However, in the immediate setting of nausea, vomiting, and a postoperative stricture, this is not the priority intervention.

Choice C reason: Providing protein-enriched shakes may be beneficial for maintaining nutrition in the long term, but it is not appropriate when the client is experiencing nausea, vomiting, and anorexia. Oral intake should be limited until the symptoms subside and the stricture is addressed.

Choice D reason: Encouraging small frequent meals may be beneficial for managing long-term nutritional needs after bariatric surgery, but it is not appropriate during an acute episode of nausea, vomiting, and anorexia. The client should be kept NPO to prevent further complications and allow for proper healing.

A. Minimize intake of spicy foods. B. Begin a smoking cessation program. C. Avoid wearing tight-fitting clothes. D. Remain upright following meals.

Correct Answer is D

Explanation

Choice A reason: Minimizing the intake of spicy foods can help reduce GERD symptoms, but it is not the most critical instruction for preventing reflux immediately after eating.

Choice B reason: Beginning a smoking cessation program is important for overall health and can help reduce GERD symptoms over time, but it is not the immediate priority for preventing reflux.

Choice C reason: Avoiding tight-fitting clothes can help reduce pressure on the abdomen and lessen reflux symptoms, but it is not the most urgent instruction to emphasize at discharge.

Choice D reason: Remaining upright following meals is crucial for preventing reflux. Lying down immediately after eating can cause stomach contents to flow back into the oesophagus, exacerbating GERD symptoms. This instruction is key to managing the condition effectively.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?

Correct Answer is D

Explanation

A male client comes to the clinic with concerns of erectile dysfunction (ED). Which information is most important for the nurse to obtain?

The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?

To ensure client adherence to the postoperative regimen, which content is most important for the nurse to include in the preoperative teaching?

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

During a home visit, the nurse should evaluate the effectiveness of a client's treatment for chronic obstructive pulmonary disease (COPD) by assessing for which primary symptom?

The nurse calculates the body mass index (BMI) for an adult client who is obese. Which additional assessment finding places the client at high risk for cardiac disease?

A client with heart failure (HF) is waiting in the preoperative area for a scheduled procedure and tells the nurse, "My heart feels like it is beating too fast and I feel faint." After initiating a call for an electrocardiogram (ECG), which assessment data is most important for the nurse to obtain?