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.
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Correct Answer is C
Explanation
Clostridium difficile is a highly contagious bacteria that can spread easily from person to person. The patient should be placed in a private room to prevent the spread of the infection to other patients. Contact isolation precautions should also be implemented, which involves wearing gloves and a gown when entering the patient's room, as well as washing hands thoroughly after leaving the room.
Options a and b are not directly related to the care of a patient with Clostridium difficile. Option d is also not directly related, although proper food handling and storage can help prevent the spread of other types of infections.
Correct Answer is D
Explanation
Cushing syndrome is a hormonal disorder caused by prolonged exposure to high levels of cortisol hormone in the body. It can cause a variety of physical manifestations, including truncal obesity, thin arms, and legs, decreased axillary and pubic hair, hypertension, glucose intolerance, osteoporosis, and purple striae (stretch marks) on the abdomen.
Out of the options given, the nurse would expect to find purplish-red streaks on the abdomen as an additional manifestation of Cushing syndrome.
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