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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A reason: Keeping toenails trimmed short is important for foot care, especially in clients with PAD, but it is not the highest priority.

Choice B reason: Applying a heating pad to soothe leg pain can provide temporary relief but does not address the underlying issue of PAD or reduce cardiovascular risk.

Choice C reason: Enrolling in a smoking cessation program is the highest priority. Smoking significantly exacerbates PAD and increases the risk of further cardiovascular events, including heart attacks. Quitting smoking is crucial for improving vascular health and reducing the risk of complications.

Choice D reason: Reducing intake of high saturated fats and salt is important for overall cardiovascular health but is not as immediate or impactful as smoking cessation in reducing the risk of complications from PAD and MI.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 developing a teaching plan for a client with peripheral arterial disease (PAD) who has a history of a myocardial infarction (MI) and smokes two packs of cigarettes daily. Which instruction has the greatest priority?

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

The home health nurse is caring for a client with Parkinson's disease who is beginning to experience swallowing difficulties. Which intervention should the nurse include in this client's plan of care?

A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and haemoglobin A1C. Which statement by the client indicates teaching has been effective?

The nurse is providing education to a client who is returning home with an indwelling urinary catheter after having a transurethral resection of the prostate (TURP). Which statement made by the client demonstrates a need for the nurse to clarify the instructions?

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?

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?

The nurse plans to provide diet instructions to a client who was recently diagnosed with diverticulosis. Which dietary modification should the nurse include in the teaching plan?