A client with systemic lupus erythematosus (SLE) is receiving nonsteroidal anti- inflammatory drug (NSAID) therapy. Which side effect of NSAID therapy should the nurse immediately report to the health care provider?

Melena

Decreased vision

Pancytopenia

Hyperglycemia

Answer and Explanation

The Correct Answer is C

Pancytopenia refers to a decrease in all three major blood cell types: red blood cells (anemia), white blood cells (leukopenia), and platelets (thrombocytopenia). It is a potentially serious side effect that can lead to increased susceptibility to infections, anemia-related symptoms (fatigue, weakness), and an increased risk of bleeding. Prompt reporting is necessary for further

evaluation and appropriate management.

While melena (dark, tarry stools) is a concerning side effect, it typically indicates gastrointestinal bleeding, which should also be reported promptly but may not require immediate action unless the bleeding is severe or accompanied by other symptoms.

Decreased vision can be a side effect of certain medications, including NSAIDs, but it does not usually require immediate reporting unless it is severe or rapidly progressive. Hyperglycemia (high blood sugar) can occur with NSAID therapy, especially in individuals with preexisting diabetes or impaired glucose tolerance. While it should be monitored and managed appropriately, it does not typically require immediate reporting unless it is extremely high or associated with other concerning symptoms.

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Correct Answer is C

Explanation

Assisting the patient to get out of bed is a task that can be safely delegated to UAP, as long as the patient's mobility and transfer status allow for assistance without the need for specialized nursing skills. UAPs are trained to provide basic patient care, including assisting with activities of daily living, under the supervision and direction of licensed healthcare professionals.

Teaching the patient to purse lip breath requires knowledge and understanding of the technique, as well as the ability to assess the patient's response and provide feedback. This is best done by a licensed healthcare professional, such as a nurse or respiratory therapist. Auscultating breath sounds every 4 hours requires the ability to correctly use a stethoscope and interpret the findings. This task falls within the scope of practice of a nurse or respiratory therapist who has received appropriate training.

Planning patient activities to minimize exertion requires knowledge of the patient's condition, limitations, and goals. It involves assessment, evaluation, and coordination of care, which are typically performed by licensed healthcare professionals.

A. Check the patency of the NG tube. B. Place the patient in a recumbent position. C. Encourage the patient to deep breathe and consciously relax. D. Assess the patient's vital signs and circulatory status.

Correct Answer is D

Explanation

The development of nausea and increased upper abdominal bowel sounds after 24 hours of NG decompression in a patient with gastric outlet obstruction raises concerns for possible complications or changes in the patient's condition. Assessing the patient's vital signs, including blood pressure, heart rate, respiratory rate, and oxygen saturation, can provide important information about their circulatory status and overall stability.

While checking the patency of the NG tube is important, it is not the best immediate action in this situation. The nurse should first assess the patient's vital signs to ensure their stability before proceeding with further interventions.

Placing the patient in a recumbent position (lying down) or encouraging deep breathing and conscious relaxation may not address the underlying issue and could potentially exacerbate the symptoms. It is essential to assess the patient's vital signs and circulatory status to determine the appropriate course of action.

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A client with systemic lupus erythematosus (SLE) is receiving nonsteroidal anti- inflammatory drug (NSAID) therapy. Which side effect of NSAID therapy should the nurse immediately report to the health care provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with COPD. Which intervention could be delegated to unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

A patient with a gastric outlet obstruction has been treated with NG decompression. After the first 24 hours, the patient develops nausea and increased upper abdominal bowel sounds. What is the best action by the nurse?

Correct Answer is D

Explanation

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