After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

Obtain current vital signs.

Measure abdominal girth.

Observe for flushing

Auscultate breath sounds.

Answer and Explanation

The Correct Answer is A

A.   Vital signs are critical for assessing the client’s current hemodynamic status. Coffee-ground emesis can indicate gastrointestinal bleeding, which might lead to complications like hypovolemia or shock.

Vital signs can provide essential information about the client’s condition and help determine the urgency of intervention. Checking vital signs is a priority in assessing the severity of the situation and guiding further actions.
B.   Measuring abdominal girth is useful in assessing for abdominal distention or fluid accumulation, which can be relevant in some gastrointestinal conditions. However, in the immediate context of coffee- ground emesis, the most urgent concern is evaluating the client's hemodynamic stability rather than focusing on abdominal girth.
C.   Flushing of the skin might be relevant in certain contexts (e.g., reactions to medications or infections), but it is not directly related to the immediate concern of gastrointestinal bleeding and the client’s hemodynamic status. It is less critical compared to assessing vital signs in this situation.
D.   While auscultating breath sounds is important for evaluating respiratory status and detecting any pulmonary complications, it is not the immediate priority in the context of coffee-ground emesis. The primary concern should be assessing for signs of hemodynamic instability that may result from gastrointestinal bleeding.

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Correct Answer is B

Explanation

A. While this information might be helpful for general medication management, it is not directly related to the client's risk for osteoporosis.
B. The amount of calcium in the multivitamin is the most crucial follow-up information. For an older adult at risk for osteoporosis, ensuring adequate calcium intake is essential for bone health. Confirming the amount of calcium in the multivitamin helps ensure that the client is receiving enough of this critical nutrient to support bone density and reduce the risk of fractures.
C. This information is not relevant to the client's bone health or risk for osteoporosis.
D. While this information can influence the absorption of certain nutrients, it is not specifically related to calcium absorption or osteoporosis prevention.

A. Ensure the IV solution is infusing at the prescribed rate. B. Listen to lung sounds. C. Notify the healthcare provider of the findings. D. Check under the back for evidence of bleeding.

Correct Answer is D

Explanation

A. Ensuring that the IV solution is infusing at the prescribed rate is an important task to maintain adequate fluid and electrolyte balance, especially if the client is experiencing signs of shock or low blood pressure. However, this action alone does not address the immediate need to assess or intervene for potential critical issues such as bleeding or severe hemodynamic instability.
B. Listening to lung sounds can help assess for pulmonary complications, such as fluid accumulation or atelectasis, which can be relevant postoperatively. However, in the context of hypotension, tachycardia, and altered mental status, the priority is to address potential critical issues related to circulatory stability and bleeding.
C. It is essential to inform the healthcare provider of the client's condition, but this should be done after initial interventions to stabilize the client. This action is necessary but not the first priority.
D. The first action should be to check for any signs of bleeding, especially after abdominal surgery where internal bleeding is a possibility.

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After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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