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.

Test stools for occult blood

Insert a nasogastric tube, attach to low suction

Administer aspirin for abdominal pain

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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Correct Answer is C

Explanation

Choice A rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can be a complication of burns. However, they are not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice B rationale
While fluid imbalance can occur with any burn due to loss of fluid from the damaged skin, it is not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice C rationale
Airway obstruction is a primary risk for a patient with burns on the head, neck, and chest. Swelling from the burns can lead to obstruction of the airway, making it difficult for the patient to breathe.
Choice D rationale
While infection is a risk with any burn, it is not typically the primary risk for a patient with burns on the head, neck, and chest. The primary risk is airway obstruction due to swelling from the burns.

A. Attached to the foot of the bed. B. Below the level of the patient’s chest. C. Along the side of the patient’s knee. D. At the level of the patient’s clavicle.

Correct Answer is B

Explanation

Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest. What is the primary risk to the client?

Correct Answer is C

Explanation

A patient arrives at the emergency department with a stab wound to the chest. The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity. Where should the nurse place the system?

Correct Answer is B

Explanation

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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.