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 A
Explanation
Choice A rationale
Given the client’s risk factors of poor wound healing, decreased bone density, and increased capillary fragility, the most appropriate outcome statement to include in the plan of care is that the client implements measures to prevent injury. This includes avoiding falls, using caution with sharp objects to prevent cuts, and taking steps to protect the bones.
Choice B rationale
While it is important for the client to understand their disease and ways to control it, this is not the most appropriate outcome statement given the client’s specific risk factors.
Choice C rationale
Improving body image may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
Choice D rationale
Experiencing a normal fluid balance may be a relevant goal for some clients with Cushing’s syndrome, but it is not the most appropriate outcome statement given the client’s specific risk factors.
Correct Answer is A
Explanation
Choice A rationale
After a gastric endoscopy, it’s common for patients to experience a sore throat. This is due to the passage of the endoscope through the throat during the procedure. The discomfort is usually temporary and can be relieved with lozenges or gargling with warm salt water.
Choice B rationale
While headaches can occur after procedures that involve sedation, they are not commonly associated with gastric endoscopy specifically. Therefore, while it’s important to monitor for headaches, they are not a typical post-procedure problem following a gastric endoscopy.
Choice C rationale
Aching legs are not a common problem following a gastric endoscopy. The procedure primarily involves the upper gastrointestinal tract, and does not directly affect the legs.
Choice D rationale
Nausea can occur after a gastric endoscopy, but it is more commonly associated with the sedation used during the procedure rather than the procedure itself. If nausea does occur, it can be managed with antiemetic medications.
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