A male client is admitted to the emergency department while vomiting dark brown, foul- smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?

Place an indwelling urinary catheter and attach a bedside drainage unit.

Send the client to x-ray for a flat plate of the abdomen.

Insert a nasogastric tube (NGT) and attach to low intermittent suction.

Give a prescribed analgesic for temperature above 101° F (38.3°C).

Answer and Explanation

The Correct Answer is C

A.   An indwelling urinary catheter is generally used for monitoring urine output in patients with urinary issues or those who are unable to void. It is not the first-line intervention for a client with symptoms suggesting a possible bowel obstruction or gastrointestinal complication. While monitoring urine output may be important, it does not address the immediate concern of the client’s gastrointestinal symptoms.
B.   An abdominal x-ray can help diagnose conditions such as bowel obstruction, ileus, or other abdominal issues by visualizing the presence of air-fluid levels or distended bowel loops. While this diagnostic step is important, it should follow interventions that might provide immediate symptomatic relief or help manage the suspected condition.
C.   Inserting an NGT and attaching it to low intermittent suction is a critical intervention for managing symptoms of bowel obstruction or severe gastrointestinal distress. The dark brown, foul-smelling vomit and hyperactive bowel sounds suggest that the client might have a bowel obstruction or significant gastrointestinal complication. An NGT can help decompress the stomach, relieve pressure, reduce vomiting, and prevent further gastrointestinal complications.
D.   While providing analgesics for pain and fever is important for overall symptom management, it does not address the immediate cause of the client’s symptoms. The focus should be on diagnosing and managing the underlying issue causing the symptoms, such as a bowel obstruction, rather than just treating pain or fever.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

"I can stop taking the phenytoin If I go for a while and don't have a seizure." This statement indicates a lack of understanding. Anti-seizure medications are typically lifelong and should not be stopped without medical advice.

"Having a medic alert bracelet might be a good idea, but it is up to me to decide if I want it or not." This statement also shows a lack of understanding. A medic alert bracelet is crucial for individuals with seizures, as it provides essential information to emergency responders in case of an emergency.

"I don't need to go to the hospital if I have another seizure unless it is a very long seizure or if I have several in a row." This statement demonstrates a lack of understanding. Any seizure should be reported to a healthcare provider, as it could indicate changes in seizure control.

“There are really no lifestyle changes that I can do that will affect my risk for having another seizure." This statement indicates a lack of understanding. Certain lifestyle factors, such as sleep deprivation, stress, and alcohol consumption, can trigger seizures.

"I may never know why! started having seizures." This statement indicates understanding. While the cause of seizures is often unknown, it's important for the client to acknowledge this possibility.

A. An adolescent who drinks a minimum of four diet drinks daily. B. A client who is too busy at work to void when the urge occurs. C. A multipara who had pyelonephritis during her last pregnancy. D. An older adult who is usually incontinent of urine during the night

Correct Answer is C

Explanation

A. While excessive consumption of certain beverages can potentially affect urinary health, diet drinks are generally not a primary risk factor for UTIs. The key risk factors for UTIs typically involve issues related to urinary retention, hygiene, and anatomical predispositions rather than beverage consumption alone.
B. Not voiding when the urge occurs, also known as urinary retention, can increase the risk of UTIs. When urine is retained in the bladder for extended periods, it can provide an environment where bacteria can proliferate, leading to infections. This behavior is a significant risk factor for developing UTIs, as it contributes to urinary stasis.
C. A multipara with a history of pyelonephritis is at increased risk for future UTIs. A history of pyelonephritis indicates that the client has experienced a serious urinary infection in the past, which could make her more susceptible to recurrent infections. This is a significant risk factor for developing UTIs again.
D. Urinary incontinence, especially in older adults, can be associated with increased risk for UTIs due to factors like poor hygiene, the presence of residual urine, and possible skin breakdown. While incontinence is a risk factor, it is often considered less directly related to recurrent UTIs compared to issues like urinary retention or a history of severe infections.

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?

Correct Answer is C

Explanation

A client with a large pleural effusion undergoes a thoracentesis. Following the procedure, which observation warrants immediate intervention by the nurse? Reference Range: Arterial Blood Gas (ABG) pH [7.35 to 7.45] PaCO, [35 to 45 mm Hg] HCO 21 to 28 mEq/L (21 to 28 mmol/L)] PaO2 [80 to 100 mm Hg]

A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?

While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Before reporting this finding to the healthcare provider, the nurse should evaluate which of the client's laboratory values?

Exhibits The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?

After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?