A client with Crohn's disease is admitted to the medical unit with a three-day history of abdominal cramping, nausea, and vomiting. Which prescription should the nurse implement first?
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).
Place an indwelling urinary catheter and attach to a bedside drainage unit.
Insert a nasogastric tube (NGT) and attach to low intermittent suction.
The Correct Answer is D
Choice A reason: Sending the client to x-ray for a flat plate of the abdomen is important for diagnosing the underlying cause of symptoms, such as bowel obstruction or severe inflammation. However, in the immediate situation, it is essential to relieve the client's symptoms and stabilize their condition first.
Choice B reason: Giving a prescribed analgesic for temperature above 101°F (38.3°C) can help manage fever and pain. However, it is not the first priority. The client’s primary issue is abdominal cramping, nausea, and vomiting, which need to be addressed urgently to prevent further complications.
Choice C reason: Placing an indwelling urinary catheter and attaching it to a bedside drainage unit may be necessary if there are urinary retention concerns. However, this intervention does not directly address the gastrointestinal symptoms that are currently most troubling for the client.
Choice D reason: Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction is the most immediate priority. This action helps to decompress the stomach, relieve nausea and vomiting, and prevent further complications such as aspiration or worsening of the obstruction. It provides immediate symptomatic relief and allows for better management of the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Joining a group weight loss program is important for the client's overall health, particularly due to obesity being a significant risk factor for gallbladder disease. Weight loss can help decrease the likelihood of gallstone formation and other gallbladder-related issues. Participation in a weight loss program can also provide support and structured guidance for achieving a healthier weight.
Choice B reason: Beginning a smoking cessation class is beneficial for the client's health, as smoking is a risk factor for many diseases, including gallbladder issues. However, in the context of reducing gallbladder disease risk, weight loss would have a more direct and immediate impact, making it the primary focus for intervention.
Choice C reason: Considering hormone replacement therapy may be relevant for managing symptoms associated with menopause. However, it is not directly related to the risk reduction for gallbladder disease. Hormone replacement therapy should be discussed with a healthcare provider to weigh the benefits and risks.
Choice D reason: Scheduling rest periods after eating is generally helpful for digestion and comfort, but it does not directly address the key risk factors for gallbladder disease in this client, such as obesity and diet. Addressing these primary risk factors through weight loss would be more effective in reducing the client's risk.
Correct Answer is C
Explanation
Choice A reason: Effectively managing pain, discomfort, and diarrhea is important for the client’s quality of life, but it does not address the long-term goal of preventing disease progression and complications.
Choice B reason: Ensuring careful fluid and electrolyte balance is critical, especially during acute exacerbations, but it is more of an immediate concern rather than a long-term goal.
Choice C reason: Reducing the number and severity of acute exacerbations is the most important long-term goal for clients with chronic ulcerative colitis. This goal focuses on maintaining remission, preventing complications, and improving overall prognosis by minimizing flare-ups.
Choice D reason: Maintaining a diet that is high in fibber content can be beneficial for overall health but may not always be suitable for clients with ulcerative colitis, especially during flare-ups. It is not the most critical long-term goal for managing the condition.
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