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 A
Explanation
Choice A rationale
Severe upper abdominal pain can be a sign of gastrointestinal perforation in a patient with peptic ulcer disease. When an ulcer erodes through the wall of the stomach or duodenum, it can cause a perforation, or hole. This is a serious complication that can cause severe pain.
Correct Answer is D
Explanation
Choice A rationale
Serum IgA levels are not typically associated with acute pancreatitis. IgA is an antibody that plays a crucial role in the immune function of mucous membranes. Changes in serum IgA levels can occur in various conditions, but they are not a characteristic finding in acute pancreatitis.
Choice B rationale
Decreased serum bilirubin is not commonly associated with acute pancreatitis. While jaundice (indicated by increased bilirubin levels) can occur in some cases of acute pancreatitis due to blockage of the bile duct, decreased bilirubin levels are not a typical finding.
Choice C rationale
Elevated serum albumin is not typically associated with acute pancreatitis. In fact, levels of albumin, a protein made by the liver, can sometimes decrease in acute pancreatitis due to inflammation and leakage of protein into the abdomen.
Choice D rationale
Elevated serum amylase is commonly associated with acute pancreatitis. Amylase is an enzyme that helps digest carbohydrates. It’s produced in the pancreas and the glands that make saliva. When the pancreas is inflamed, levels of amylase in the blood often rise.
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