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 D
Explanation
The patient has been diagnosed with type 2 diabetes and reports following a reduced-calorie diet but has not lost any weight. This suggests that the patient may not be following the diet as prescribed or may have other factors affecting their blood glucose levels. Additionally, the patient did not bring their glucose monitoring record, which is an important tool for assessing blood glucose control over time.
In this situation, obtaining a fasting blood glucose level or an oral glucose tolerance test may provide a snapshot of the patient's blood glucose level at the time of the test, but these tests do not provide information about blood glucose control over the past few months. A urine dipstick for glucose is a less reliable method for assessing blood glucose control and is not recommended for routine monitoring.
Therefore, obtaining a glycosylated hemoglobin (HbA1c) level is the most appropriate test in this situation. HbA1c reflects the average blood glucose level over the past 2-3 months and is recommended for routine monitoring of blood glucose control in patients with diabetes. This test can provide valuable information about the effectiveness of the patient's diet and any other interventions aimed at controlling their blood glucose levels.
Correct Answer is C
Explanation
Type 2 diabetes mellitus is a metabolic disorder characterized by high blood sugar levels resulting from decreased insulin secretion and/or increased insulin resistance. In type 2 diabetes, the body's cells become resistant to insulin, which is a hormone that helps regulate blood sugar levels by allowing glucose to enter cells for energy. As a result, the pancreas produces more insulin to compensate for the increased demand, but over time, the pancreas may not be able to keep up, and blood sugar levels rise.
Unlike type 1 diabetes, which is an autoimmune disorder in which the body's immune system destroys the insulin-producing cells in the pancreas, people with type 2 diabetes still produce insulin, but their body is not able to use it effectively. Therefore, type 2 diabetes can be managed through lifestyle changes, such as diet and exercise, and/or medication, such as oral hypoglycemic agents or insulin therapy.
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