A nurse is admitting a client. Review the exhibits to answer the question.
For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated.
Test stools for occult blood
Insert a nasogastric tube, attach to low suction
Administer aspirin for abdominal pain
Initiate IV fluids
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Based on the provided exhibits, here are the considerations for the provider’s prescriptions:
- Test stools for occult blood: Anticipated. Given the client’s report of vomiting brown emesis, which could indicate gastrointestinal bleeding, testing stools for occult blood is a standard diagnostic approach to confirm or rule out bleeding.
- Insert a nasogastric tube, attach to low suction: Anticipated. The client has vomited coffee ground emesis, which is a sign of possible upper gastrointestinal bleeding. A nasogastric tube can help decompress the stomach and remove any remaining blood or gastric contents.
- Administer aspirin for abdominal pain: Contraindicated. Aspirin can exacerbate gastrointestinal bleeding, especially in a client with a history of GERD and current symptoms that may suggest a gastrointestinal bleed.
- Initiate IV fluids: Anticipated. The client’s vital signs indicate tachycardia and hypotension, which, along with the clinical presentation, suggest volume depletion possibly due to vomiting and potential bleeding. IV fluids are necessary to maintain hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The Semi-Fowler’s position, while commonly used for patients with respiratory issues, is not the most effective position for relieving pain in acute pancreatitis.
Choice B rationale
Lying prone with a pillow under the abdomen is not typically recommended for acute pancreatitis pain relief.
Choice C rationale
Lying supine with legs elevated and head on a small pillow is not typically recommended for acute pancreatitis pain relief.
Choice D rationale
Sitting in a chair, leaning forward with a pillow for back support, is often recommended for pain relief in acute pancreatitis. This position can help decrease the pressure on the abdomen and relieve pain.
Correct Answer is D
Explanation
Choice A rationale
While pain management is important in burn care, the first action should be to stop the burning process. Administering IV morphine does not achieve this.
Choice B rationale
Applying ice to a burn can cause vasoconstriction and may increase tissue damage. It is not the first action to stop the burning process.
Choice C rationale
Applying a neutralizing agent is not the first action in chemical burn management. The priority is to remove the chemical from contact with the skin.
Choice D rationale
Removing the patient’s clothing is the first action in burn management. This prevents further contact of the chemical with the skin and stops the burning process.
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