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. This action is typically used in the treatment of hyperkalemia (high potassium levels), not hypokalemia. The combination of glucose and insulin is used to temporarily drive potassium into cells and lower serum potassium levels. For severe hypokalemia, the priority is to administer potassium replacement therapy rather than attempting to lower potassium levels, as the client needs to correct the deficiency.
B. Severe hypokalemia requires prompt correction to prevent complications. Potassium replacement should be administered according to healthcare provider orders. This may involve oral or intravenous potassium supplements, depending on the severity of the hypokalemia and the client's condition. Informing the healthcare provider is essential for ensuring that appropriate and timely treatment is provided.
C. While increasing potassium intake through diet is important for managing mild cases of hypokalemia, a serum potassium level of 2.5 mEq/L is severe and likely requires immediate medical intervention. Dietary changes alone are insufficient and not timely enough to address such a critical deficiency.
D. Monitoring urinary output is important in managing electrolyte imbalances to assess kidney function and fluid balance, but it is not the primary intervention for severe hypokalemia. The immediate priority is to address the low potassium level through appropriate replacement therapy.

A. Teach about compliance to reduce blood pressure. B. Provide rest periods and portable oxygen. C. Maintain continuous monitoring of heart rate and rhythm. D. Administer nitroglycerin daily.

Correct Answer is A

Explanation

A. This is the most likely intervention to avert cardiomegaly and improve myocardial contractility. By reducing blood pressure, the heart doesn't have to work as hard to pump blood, which can help prevent the heart from enlarging (cardiomegaly) and improve its ability to contract effectively.
B. While rest and oxygen can help manage symptoms of heart failure, they do not directly address the underlying issue of increased cardiac workload and hypertrophy.
C. Monitoring heart rate and rhythm is important for assessing the patient's condition, but it does not prevent cardiomegaly or improve contractility.
D. Nitroglycerin is used to treat acute symptoms of heart failure, such as chest pain, but it is not a long- term solution for preventing cardiomegaly or improving contractility.

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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?

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Naxlex Comprehensive Predictor Exams

The client's laboratory results indicate that the serum potassium level is 2.5 mEq/L (2.5 mmol/L). Which action should the nurse take? Reference Range: Potassium (K+) [3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L)]

Correct Answer is B

Explanation

A client is admitted with heart failure (HF) and left ventricular hypertrophy. Which intervention is most likely to avert development of cardiomegaly and improve myocardial contractility?

Correct Answer is A

Explanation

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