A nurse in a medical-surgical unit is caring for a clent
Complete the following sentence by using the lists of options.
The nurse should first address the
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for Correct Choices:
- Pain level: The client reports severe epigastric pain radiating to the back with a pain score increasing from 7 to 9 out of 10. Managing this acute pain is critical to improve the client's comfort, reduce stress response, and help prevent complications such as respiratory distress caused by shallow breathing due to pain.
- Blood pressure: The client’s blood pressure has dropped to 86/48 mm Hg, indicating hypotension that can lead to poor tissue perfusion and shock. After addressing pain, stabilizing blood pressure is essential to prevent organ dysfunction and maintain hemodynamic stability.
Rationale for Incorrect Choices:
- Lung sounds: Although diminished breath sounds and rhonchi are concerning and may indicate complications, immediate pain control can improve respiratory effort and oxygenation before focusing on lung sounds.
- Bowel sounds: Hypoactive bowel sounds are common in pancreatitis but are less urgent than pain and hypotension in acute care.
- Temperature: Fever suggests infection or inflammation but is a lower priority compared to controlling pain and stabilizing blood pressure.
- Blood glucose level: Elevated glucose requires monitoring but is less urgent than the client’s pain and hypotension in the acute phase.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. “Use an electric razor when shaving while taking this medication.” Warfarin increases bleeding risk by inhibiting vitamin K–dependent clotting factors. Using an electric razor reduces the chance of cuts and bleeding during shaving, making this a critical safety teaching point.
B. “This medication can cause back pain” Back pain is not a common or expected side effect of warfarin. If a client on warfarin experiences unexplained back pain, it should be evaluated as it could indicate internal bleeding, but it is not typical enough to be part of routine teaching.
C. "Take the last dose of the day 1 hour before bedtime” Warfarin is usually taken once daily, preferably at the same time, but timing in relation to bedtime is not required. The key is consistency and regular INR monitoring to guide dosing.
D. “Avoid taking the medication with milk products” Unlike some antibiotics, warfarin’s absorption is not significantly affected by dairy. Dietary consistency with vitamin K is more important than avoiding milk, and milk products are not contraindicated.
Correct Answer is ["C","D"]
Explanation
Rationale:
A. Remove the thermometer from the client’s room for use on another client: Equipment used for clients with C. difficile should be dedicated or properly disinfected before reuse. Removing and using the same thermometer on other clients without disinfection increases the risk of cross-contamination.
B. Wash hands with an alcohol-based cleaner: Alcohol-based hand sanitizers are ineffective against C. difficile spores. Handwashing with soap and water is required to physically remove the spores from the hands.
C. Change gloves after contact with infectious material: Gloves must be changed between tasks and after contact with infectious material to prevent spread. This is standard contact precaution practice for C. difficile infections.
D. Wear a gown when providing care: A gown should be worn during any direct care or activities likely to involve contact with the client or contaminated surfaces, as C. difficile is transmitted via the fecal-oral route and can persist on surfaces.
E. Wear an N95 respirator when providing care: An N95 respirator is not required for C. difficile, which is transmitted through contact, not airborne routes. Standard and contact precautions, not airborne, are appropriate.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.