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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The plan of care for a patient with hypothermia and ﬂuid volume excess would typically include measures to increase the patient's body temperature and decrease their ﬂuid volume. Therefore, option a (ﬂuid restriction) would be appropriate for this patient.

Options b (administration of hypotonic IV ﬂuids) and d (administration of ion-exchange resin) would not be appropriate because they would increase the patient's ﬂuid volume rather than decrease it.

Option c (placement of an indwelling urinary catheter) may be appropriate to closely monitor the patient's urine output, which is an important indicator of their ﬂuid status. However, this alone would not be sufficient to manage the patient's hypothermia and ﬂuid volume excess.

A. I Will add broccoli and kale to my diet." B. I will stop taking my calcium supplements if they irritate my stomach." C. I need to avoid foods with vitamin D because I am allergic to milk. D. I will eat more cheese because I can't drink milk.

Correct Answer is A

Explanation

Broccoli and kale are good sources of calcium, and by adding them to their diet, the client can increase their calcium intake without consuming milk. It is important to note that some calcium supplements may irritate the stomach but stopping them altogether is not advisable without consulting a healthcare provider. Vitamin D is not a milk product, and it is essential for calcium absorption. Avoiding foods with vitamin D can worsen the low calcium levels. Cheese is a milk product and may not be suitable for someone with a milk allergy.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with hypothermia and ﬂuid volume excess. Which of the following would be included in the plan of care?

Correct Answer is A

Explanation

A nurse is teaching nutritional strategies to a client who has a low calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse is preparing a client for discharge home who is confused and incontinent after a stroke. Which instructions regarding bladder training will the nurse include in the teaching plan for the client's family?

While assessing a patient who has just arrived in the post-anesthesia recovery unit (PACU) after a thyroidectomy, the nurse obtains this data. Which is the most important to communicate to the surgeon?

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