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 B
Explanation
Diabetes insipidus is a condition where the body is not able to regulate water balance properly, leading to excessive urine output and dehydration. The patient's urine output of 800 ml/hr (option A) and low urine specific gravity of 1.003 (option C) is consistent with diabetes insipidus and requires monitoring, but they are not as immediately concerning as the patient's confusion and lethargy.
Confusion and lethargy may indicate severe dehydration, electrolyte imbalances, or even brain swelling (if the patient had a recent head injury, as mentioned in option D). These symptoms require immediate attention to prevent further complications and ensure the patient's safety.
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.
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