A nurse is planning care for a client who has upper gastrointestinal bleeding due to a peptic ulcer.
Which of the following actions should the nurse plan to take?
Ensure that the client has a 22-gauge IV line in place.
Provide ketorolac for abdominal pain.
Administer nitroprusside IV based on the client's weight.
Insert a large-bore nasogastric tube.
The Correct Answer is D
The nurse should plan to insert a large-bore nasogastric tube for a client who has upper gastrointestinal bleeding due to a peptic ulcer.
This allows for gastric lavage and can help diagnose the source of bleeding.
Choice A is wrong because a 22-gauge IV line may be too small for rapid fluid resuscitation.
Choice B is wrong because ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of gastrointestinal bleeding.
Choice C is wrong because nitroprusside is a vasodilator used to treat hypertensive emergencies and is not typically used for upper gastrointestinal bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Monitor the client for adequate urine output.
When administering potassium chloride via IV infusion to a client who has severe hypokalemia, it is important for the nurse to monitor the client’s urine output to ensure that their kidneys are functioning properly and that they are able to excrete excess potassium.
Choice A is incorrect because the infusion site should be checked more frequently than every 4 hours.
Choice B is incorrect because the maximum recommended rate of infusion for potassium chloride is 10 mEq/hr.
Choice C is incorrect because Chvostek’s sign is used to assess for hypocalcemia, not hypokalemia.
Correct Answer is B
Explanation
Pitting edema is a common and obvious symptom of right-sided heart failure.
This occurs when fluid retention causes swelling in the lower limbs and sometimes the abdomen.
Choice A is incorrect because poor skin turgor is not a common symptom of right-sided heart failure.
Choice C is incorrect because oliguria, or decreased urine output, is not a common symptom of right-sided heart failure.
Choice D is incorrect because S4 galloping heart sounds are not a common symptom of right-sided heart failure.
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