A with acute Gl bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the healthcare provider?
The patient's lungs have crackles audible to the midline.
The patient's BP has increased to 142/94 mm Hg.
The bowel sounds are very hyperactive in all four quadrants.
The NG suction is returning coffee-ground material.
The Correct Answer is D
Coffee-ground material in the NG suction indicates that there is active bleeding in the upper gastrointestinal tract, which could be a life-threatening situation. This requires immediate medical attention and intervention to control the bleeding and stabilize the patient.
Options A, B, and C are also important assessment data, but they are not as urgent as option D in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This statement is correct. Impaired fasting glucose (IFG) is a condition in which the fasting blood glucose level is higher than normal but not high enough to be diagnosed as diabetes. However, people with IFG are at increased risk of developing type 2 diabetes and cardiovascular disease. Weight loss and exercise can help to prevent or delay the onset of diabetes and reduce the risk of cardiovascular disease.
Correct Answer is D
Explanation
Although increasing fluid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is effective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.
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