A client with peptic ulcer disease (PUD) is admitted to the medical unit. Which assessment finding requires the most immediate intervention by the nurse?

A haemoglobin of 12 g/dL (7.45 mmol/L) and haematocrit of 42% (0.42 volume fraction).

Vital signs are temperature 99.0°F (37.2°C) orally, heart rate 94 beats/minute, respirations 18 breaths/minute, blood pressure 110/70 mm Hg.

Vomits coffee-grounds emesis.

Reports having sharp epigastric pain.

Answer and Explanation

The Correct Answer is C

Choice A reason: A haemoglobin level of 12 g/dL (7.45 mmol/L) and haematocrit of 42% (0.42 volume fraction) are slightly lower than the reference range but not critically low. This finding is important and needs to be monitored, but it does not require the most immediate intervention.

Choice B reason: The vital signs provided are within normal limits and do not indicate an urgent or life-threatening condition. These should be monitored, but they do not require immediate intervention compared to other findings.

Choice C reason: Vomiting coffee-grounds emesis is a sign of gastrointestinal bleeding, specifically indicating that blood has been in the stomach long enough to be partially digested by stomach acid, giving it a coffee-grounds appearance. This is a serious and potentially life-threatening condition requiring immediate medical intervention to stop the bleeding and prevent further complications.

Choice D reason: Sharp epigastric pain is a common symptom of peptic ulcer disease and indicates inflammation or ulceration. While it is painful and concerning, it does not require the most immediate intervention compared to active gastrointestinal bleeding.

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Correct Answer is A

Explanation

Choice A reason: Elevating the head of the bed to 90 degrees is crucial for clients in respiratory distress. This position helps to maximize lung expansion, improve breathing, and alleviate respiratory effort. It provides immediate support to enhance oxygenation and ventilation.

Choice B reason: Monitoring pulse oximetry is important for assessing the client's oxygenation status but should be done continuously rather than every 2 hours in a client in respiratory distress.

Choice C reason: Determining exposure to asthmatic triggers is relevant for long-term management but not the immediate priority in an acute situation where the client is in respiratory distress.

Choice D reason: Teaching the proper use of a rescue inhaler is essential but should be done after stabilizing the client's condition. The immediate focus should be on interventions that provide rapid relief from respiratory distress.

A. Drinks several bottles of carbonated water daily. B. Eats a vegetarian diet with cheese 2 to 3 times a day. C. Experiences additional stress since adopting a child. D. Jogs more frequently than usual daily routine.

Correct Answer is B

Explanation

Choice A reason: Drinking several bottles of carbonated water daily is not a well-established risk factor for renal calculi. While hydration is important in preventing kidney stones, carbonation itself does not significantly increase the risk.

Choice B reason: Eating a vegetarian diet with cheese 2 to 3 times a day can increase the risk for kidney stones, especially if the cheese is high in calcium or oxalates. Dairy products, including cheese, contain calcium, and excessive consumption can contribute to the formation of calcium oxalate stones, which are the most common type of kidney stones.

Choice C reason: Experiencing additional stress since adopting a child is not directly related to the formation of kidney stones. Stress can have various health impacts, but it is not a known primary risk factor for renal calculi.

Choice D reason: Jogging more frequently than the usual daily routine is not associated with an increased risk of kidney stones. Regular physical activity is generally beneficial for overall health and does not contribute to the formation of renal calculi.

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A client with peptic ulcer disease (PUD) is admitted to the medical unit. Which assessment finding requires the most immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After initializing a steroid nebulizer treatment for an asthmatic client in respiratory distress, which intervention is most important for the nurse to implement?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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