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 C

Explanation

Choice A reason: Reporting black stools to the healthcare provider is important because black stools can indicate gastrointestinal bleeding, which is a serious complication of gastritis. This statement reflects proper understanding and does not need additional education.

Choice B reason: Consuming caffeine in moderation is advisable because excessive caffeine can irritate the stomach lining and exacerbate gastritis symptoms. This statement is correct and shows proper understanding.

Choice C reason: Drinking plenty of water with meals might seem beneficial, but it can actually dilute stomach acid and interfere with digestion, potentially worsening gastritis symptoms. Instead, it is recommended to drink water between meals to stay hydrated without impacting digestion.

Choice D reason: Avoiding ibuprofen for headaches is important because nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can irritate the stomach lining and worsen gastritis. This statement reflects proper understanding and does not need additional education.

A. Notify the charge nurse that the client will need assignment to the COVID-19 specified area of the facility. B. Place the nasal swab specimen for COVID-19 directly into a biohazard bag. C. Maintain a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions. D. Start an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results.

Correct Answer is C

Explanation

Choice A reason: Notifying the charge nurse that the client will need assignment to the COVID-19 specified area of the facility is an important action for infection control. However, the most immediate priority is to protect oneself and others by maintaining appropriate distance and using PPE.

Choice B reason: Placing the nasal swab specimen for COVID-19 directly into a biohazard bag is necessary for safe specimen handling and to prevent contamination. While important, it follows after ensuring that proper PPE is used and distancing measures are maintained.

Choice C reason: Maintaining a 6 feet (1.8 meters) distance from the client unless wearing an N95 respirator and personal protective equipment (PPE) for droplet precautions is the most crucial action. This step ensures the nurse’s safety and reduces the risk of virus transmission. Proper PPE and distancing protocols are essential in managing a suspected COVID-19 case.

Choice D reason: Starting an intravenous infusion for an antiviral drug to be administered for positive COVID-19 test results is part of the treatment plan if the test comes back positive. However, this step comes after ensuring safety through proper use of PPE and maintaining distance from the client.

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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

The nurse is teaching a client with gastritis about self-management. Which statement made by the client should the nurse recognize as needing additional education?

Correct Answer is C

Explanation

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?

Correct Answer is C

Explanation

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