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 C

Explanation

The nurse should act on the order to insert a 16 French retention catheter first. The patient's markedly distended bladder and agitated and confused state suggest acute urinary retention, which can be relieved by inserting a catheter to drain the urine. This is a priority intervention as urinary retention can lead to serious complications such as bladder rupture, hydronephrosis, and renal failure. Once the catheter is inserted and the patient's bladder is drained, the healthcare provider can order further tests such as an IVP or blood tests to assess renal function. The order for lorazepam can be addressed after the catheter is inserted and the patient's urinary retention is addressed.

A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

Correct Answer is A

Explanation

Based on the given arterial blood gas results, the patient's pH is elevated, indicating alkalosis. The PaCO2 level is decreased, which suggests respiratory compensation. The bicarbonate (HCO3-) level is within the normal range. Therefore, the interpretation of the arterial blood gas results is respiratory alkalosis.

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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

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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