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A nurse is admitting a client. Review the exhibits to answer the question.

Exhibits

For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated.

A.

Test stools for occult blood

B.

Insert a nasogastric tube, attach to low suction

C.

Administer aspirin for abdominal pain

D.

Initiate IV fluids

Answer and Explanation

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.


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Related Questions

Correct Answer is A

Explanation

Choice A rationale
During the fluid resuscitation phase of burn management, the primary goal is to restore circulating volume and preserve vital organ and tissue perfusion. One of the most effective methods for assessing the results of fluid resuscitation is monitoring urine output. A urine output greater than 0.5 mL/kg/hr is generally considered an indicator of adequate fluid resuscitation.
Choice B rationale
While clear bilateral breath sounds are an important part of overall patient assessment, they are not the best method for assessing the results of fluid resuscitation in burn management.
Choice C rationale
Serum hemoglobin is not the best indicator for assessing the results of fluid resuscitation in burn management. While it can provide information about the patient’s overall health and blood volume, it does not directly reflect the adequacy of fluid resuscitation.
Choice D rationale
A heart rate of 122/min could indicate a response to pain, anxiety, or inadequate fluid resuscitation. However, it is not the best method for assessing the results of fluid resuscitation in burn management.

Correct Answer is B

Explanation

Choice A rationale
A 33-year-old with burns to the back and shoulders. While this patient’s injuries are serious, they are not immediately life-threatening. The back and shoulders are not vital areas, and while pain management and wound care will be necessary, this patient’s situation is not as urgent as others.
Choice B rationale
A 32-year-old with burns on the hands and face. This patient should be attended to first. Burns on the hands and face are more serious due to the high risk of infection and the potential for complications such as impaired breathing if the airway swells or becomes blocked due to the burns. Immediate treatment can help to prevent these complications.
Choice C rationale
A 42-year-old with burns on both legs. While these burns are serious, they are not immediately life-threatening. The patient will need pain management and wound care, and may have mobility issues, but their vital organs are not directly impacted by the burns.
Choice D rationale
A 25-year-old with a burn on the left arm. This patient, while in need of treatment, is not the highest priority. A burn on the arm, while painful and requiring treatment, is not as potentially serious or life-threatening as burns to the face, hands, or major portions of the body.

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