An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Palpate all peripheral pulses in the extremities.

Encourage cough and deep breathing exercises.

Complete a focused assessment of the abdomen.

Initiate measurement of fluid intake and output.

Answer and Explanation

The Correct Answer is C

A.   While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B.   These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C.   Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D.   Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

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Correct Answer is C

Explanation

A. This would indicate fluid volume deficit, not improvement. Increasing IV fluids should lead to a decrease in hematocrit, not an increase.
B. This is not a desired outcome for a patient with pancreatitis, as hyperglycemia is a common complication. The focus should be on maintaining stable blood glucose levels.
C. BUN is a marker of kidney function and hydration status. A decrease in BUN indicates improved renal perfusion, which is a therapeutic outcome of increasing IV fluids.
D. While a decrease in amylase is generally a good sign for pancreatitis, it is not a direct result of increasing IV fluids. Amylase levels decrease as the pancreatitis improves.

A. Assist the client with learning how to set priorities and pace activities. B. Instruct the client about the importance of maintaining bedrest. C. Consult the discharge planner about transferring the client to an assisted living center. D. Offer assurance that the fatigue inducing stage of the disease does not last.

Correct Answer is A

Explanation

A. RA often causes joint pain and stiffness, which can make it challenging to complete daily activities. Teaching the client how to set priorities and pace their activities helps them balance exertion with rest, thus reducing fatigue and improving overall function. This approach supports effective management of their condition by preventing overexertion and allowing time for recovery.
B. While rest is important for managing fatigue, strict bedrest is generally not recommended for RA patients. Prolonged bedrest can lead to muscle weakness, joint stiffness, and decreased mobility. Active management through appropriate rest and activity is usually more beneficial than complete bedrest.
C. Transferring to an assisted living center may be appropriate for some clients, but this intervention is not necessarily related to managing fatigue due to rheumatoid arthritis in the current context. This
decision would typically depend on the overall level of care needed and the client’s living situation.
D. While providing reassurance is part of supportive care, it’s important to address the specific needs and management strategies for fatigue. Simply offering assurance without practical interventions may not effectively address the client’s current symptoms or help them manage their condition in the long
term.

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An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

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Correct Answer is C

Explanation

The nurse establishes a nursing problem of "Fatigue related to inability to rest comfortably secondary to rheumatoid arthritis." Which nursing intervention should the nurse include in the plan of care for this client?

Correct Answer is A

Explanation

The nurse has determined that a client with trigeminal neuralgia has the nursing problem, "Imbalanced nutrition, less than body requirements." Which cause is most likely contributing to the problem?

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which intervention should the nurse include in the client's plan of care?

A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?

A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

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?

An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?