An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.
He hasn’t had a bowel movement in 7 days, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.
In what order should the nurse perform the following interventions? Arrange from highest to lowest priority.
Complete a focused assessment.
Offer PRN pain medication.
Send the emesis sample to the lab.
Elevate the head of the bed.
The Correct Answer is A,D,B,C
- Complete a focused assessment: The first step in managing a patient with abdominal pain and other symptoms is to perform a comprehensive assessment. This will help identify the cause of the symptoms and guide subsequent interventions.
- Offer PRN pain medication: Once the immediate risks have been addressed, managing the patient’s pain is a priority. However, the choice of pain medication will depend on the results of the assessment.
- Send the emesis sample to the lab: Sending the emesis sample to the lab can provide valuable information about the cause of the patient’s symptoms. However, this is not as urgent as the other interventions.
- Elevate the head of the bed: Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has vomited. This should be done as soon as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Vegetarian lasagna with cheese and spinach, a tossed green salad with ranch dressing, and fresh fruit is a balanced meal. However, it may not be the best choice for a patient with type 2 diabetes due to the high carbohydrate content in the lasagna and the dressing.
Choice B rationale
Fried chicken breast, mashed potatoes, green beans, sliced tomatoes, and fresh apple pie is not the best choice for a patient with type 2 diabetes. Fried foods and mashed potatoes are high in carbohydrates and fats, which can raise blood sugar levels.
Choice C rationale
Grilled fish with whole-grain brown rice, steamed broccoli, and a pear poached in red wine is a good choice for a patient with type 2 diabetes. This meal is balanced with lean protein, whole grains, and vegetables, which can help control blood sugar levels.
Choice D rationale
Lean hamburger with cheese, tomato, and lettuce on a whole-wheat bun, and angel food cake is not the best choice for a patient with type 2 diabetes. Although the hamburger is lean, the whole-wheat bun and angel food cake are high in carbohydrates, which can raise blood sugar levels.
Correct Answer is A
Explanation
Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.
Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.
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