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 B

Explanation

Based on the given documentation, the nurse suspects that the client has respiratory alkalosis. The client's ABG results show a pH of 7.52, which indicates alkalosis and the PaO2 level is slightly low, suggesting respiratory involvement. Rapid breathing (RR44) and wheezing also support the possibility of respiratory alkalosis.

A. admitting, identifying, and assessing the patient. B. counting sponges, needles, and surgical instruments. C. passing instruments to the surgeon and assistants. D. preparing the instrument table and sterile equipment.

Correct Answer is B

Explanation

Counting sponges, needles, and surgical instruments is an intraoperative activity that is specific to the circulating function of the perioperative nurse. The nurse is responsible for maintaining an accurate count of all surgical items to prevent leaving any foreign objects inside the patient after the surgery. This is a crucial task to ensure patient safety and prevent any potential complications that may arise from such errors.

Option a. admitting, identifying, and assessing the patient, is a preoperative function that is usually performed by the preoperative nurse.

Option c. passing instruments to the surgeon and assistants, is a scrub nurse function that requires knowledge of the surgical procedure and a sterile technique.

Option d. preparing the instrument table and sterile equipment is also a scrub nurse function that requires expertise in sterile technique, knowledge of surgical procedures, and the ability to maintain a sterile environment.

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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?

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Naxlex Comprehensive Predictor Exams

A client comes to the emergency department with Asthma. Based on the documentation noted below, the nurse suspects that the client has what abnormality? 10/1/2022 at 18:30 Client wheezing, RR44, BP 140/90, HR 104, T 98.4 F, ABG results show pH 7.52 mmHg, HCO3-26, PaO2 90 mmHg C. Wynn RN

Correct Answer is B

Explanation

One of the intraoperative activities that are performed by the perioperative nurse and are specific to the circulating function is:

Correct Answer is B

Explanation

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?

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