A nurse is assisting with the care of a client who is admitted to the medical surgical unit.

Complete the following sentences by using the list of options:

The nurse anticipates the client will likely require
__
as evidenced by the client’s
_
and
____
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C","dropdown-group-3":"C"}

The nurse anticipates the client will likely require blood transfusion as evidenced by the client’s low hemoglobin and low hematocrit.

Rationale:

(i)

B. Blood transfusion: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting anemia due to gastrointestinal blood loss. A blood transfusion may be necessary to restore adequate oxygen-carrying capacity and prevent further hemodynamic instability.

(ii)

C. Low hemoglobin: A hemoglobin level below normal indicates blood loss, likely from a bleeding peptic ulcer. This finding supports the need for intervention to prevent further complications such as hypoxia or shock.

F. Low hematocrit: A low hematocrit confirms anemia and blood volume depletion. This finding, along with the client's symptoms and history of dark, tarry stools, further supports the need for a blood transfusion.

Incorrect:

(i)

A. Proton pump inhibitor therapy: While PPIs are essential for ulcer management, they do not immediately address acute blood loss

C. Antibiotic therapy: Antibiotics are needed to eradicate H. pylori, but they are not the primary intervention for anemia.

D. Surgical intervention: Surgery is considered only if bleeding is severe and refractory to medical management.

E. Intravenous fluid resuscitation: IV fluids can help stabilize blood pressure but do not directly correct anemia.

(ii)

A. Elevated white blood cell count: The client’s WBC count is normal, making it irrelevant to this scenario.

B. Positive H. pylori test: While H. pylori is the likely cause of the ulcer, this result does not directly indicate the need for a blood transfusion.

D. Epigastric tenderness: This is a symptom of peptic ulcer disease but does not directly relate to the need for a blood transfusion.

E. Dark, tarry stools: While indicative of gastrointestinal bleeding, the direct lab evidence of anemia (low hemoglobin and hematocrit) is more critical in determining the need for transfusion.

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Correct Answer is A

Explanation

A) "I will stop what I am doing and lie down.": This is the correct response. When a client with stable angina experiences chest pain, they should stop any physical activity and rest in a comfortable position, preferably lying down. This helps reduce the heart’s workload and decrease the demand for oxygen, which can relieve the pain. Rest is important before taking any further action.

B) "I will take two 325 milligram aspirin tablets at the same time.": While aspirin can help reduce blood clot formation in some cases of chest pain, the recommended dosage is typically one 81-325 mg aspirin, not two 325 mg tablets. Taking two large doses may lead to an overdose or unwanted side effects. Additionally, this is not the immediate intervention for stable angina pain, which typically responds to rest and nitroglycerin.

C) "I will hold my breath and bear down.": This technique, known as the Valsalva maneuver, can increase intrathoracic pressure and slow the heart rate, but it is not recommended to relieve chest pain in stable angina. In fact, it could increase stress on the heart and worsen the symptoms. This maneuver is used in specific situations, such as slowing a rapid heart rate, not for chest pain relief.

D) "I will call the provider after taking one dose of nitroglycerin.": The client should first try nitroglycerin for chest pain as prescribed, and if the pain doesn’t resolve after one dose (or if it worsens), they should seek medical attention. However, in the case of stable angina, it's more appropriate to call the provider if the chest pain persists despite rest and nitroglycerin, not immediately after the first dose.

A. I should eat a high fat diet for several weeks B. I should expect to have diarrhea until my diet changes C. I should expect to have nausea for several days D. I should leave my steri-strips on until they fall off."

Correct Answer is D

Explanation

A) "I should eat a high fat diet for several weeks": After a laparoscopic cholecystectomy, the client is typically advised to avoid high-fat foods for a period of time as the body adjusts to the absence of the gallbladder. High-fat foods can trigger discomfort, nausea, or diarrhea. Therefore, recommending a high-fat diet is not appropriate post-surgery.

B) "I should expect to have diarrhea until my diet changes": Diarrhea is a possible side effect following gallbladder removal, particularly due to the changes in bile flow. However, the client should not expect diarrhea indefinitely. Over time, the digestive system adjusts, and with dietary modifications, diarrhea often resolves. The client should not assume this will persist unless directed by the healthcare provider.

C) "I should expect to have nausea for several days": Nausea is not typically expected to last for several days following a laparoscopic cholecystectomy. While mild nausea can occur shortly after surgery, it should subside within a short time. If nausea persists beyond this period, the client should notify their healthcare provider for further evaluation.

D) "I should leave my steri-strips on until they fall off.": Steri-strips are used to help close the incision site and should remain in place until they naturally fall off, which usually occurs within 7–10 days after surgery. This statement indicates that the client understands the proper care for their incision site. It is important not to remove them prematurely to avoid disrupting the healing process.

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A nurse is assisting with the care of a client who is admitted to the medical surgical unit. Complete the following sentences by using the list of options: The nurse anticipates the client will likely require ______ as evidenced by the client’s _______ and ______.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with client who has stable angina pectoris. Which of the following statements by the client indicates an understanding of what to do when chest pain occurs?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who is postoperative following a laparoscopic cholecystectomy. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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A nurse is assisting with the care of a client who is admitted to the medical surgical unit.

Complete the following sentences by using the list of options:

The nurse anticipates the client will likely require
__
as evidenced by the client’s
_
and
____
.