An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150 mL of dark brown emesis. In which order should the nurse implement these interventions? (Arrange with the highest priority intervention on top, and lowest priority intervention on bottom.)

Elevate the head of the bed.

Complete focused assessment.

Send emesis sample to the lab.

Offer PRN pain medication

Answer and Explanation

The Correct Answer is A,B,C,D

A.   Elevate the head of the bed. This intervention is the highest priority to prevent aspiration and improve the client's comfort and breathing.
B.   Complete focused assessment. A thorough assessment is necessary to gather more information about the client's condition and guide further interventions.
C.   Send emesis sample to the lab. This helps in diagnosing the underlying cause of the dark brown emesis, which could indicate a serious gastrointestinal issue.
D.   Offer PRN pain medication. Pain management is important but should be done after addressing immediate safety concerns and gathering sufficient assessment data.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Measure and record the client's urinary output every day.
While monitoring urinary output is important, it is not as directly related to the safety concerns associated with the new medications and the client's current state.

B. Obtain a blood pressure reading before the client gets out of bed.
This is the correct answer because both antidepressants and sedatives can cause orthostatic hypotension, which could lead to falls or other complications. Monitoring blood pressure before the client gets up helps to prevent these issues.

C. Obtain the client's vital signs every 4 hours when awake.
Regular vital sign monitoring is important, but specific attention to orthostatic changes is more critical in this scenario.

D. Provide the client with teaching regarding a cardiac diet.
While dietary education is important for long-term health management, it does not address the immediate risk associated with the prescribed medications and potential orthostatic hypotension.

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. B. The choice of treatment is best determined by the sensitivity of these genetic markers. C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. D. The prognosis of breast cancer is most successful when these markers are inherited mutations.

Correct Answer is C

Explanation

A. BRCA1 and BRCA2 provide protection of mature, functioning breast and ovarian cells. This is not accurate; BRCA1 and BRCA2 genes are involved in DNA repair, and mutations in these genes increase cancer risk.
B. The choice of treatment is best determined by the sensitivity of these genetic markers. While genetic markers can influence treatment decisions, this option does not directly address the role of BRCA1 and BRCA2 mutations in cancer risk.
C. Mutations in BRCA1 or BRCA2 identify a client's risk for cancerous cell development in breast tissue. This is correct. Mutations in these genes significantly increase the risk of developing breast and ovarian cancer.
D. The prognosis of breast cancer is most successful when these markers are inherited mutations.
This statement is incorrect. The presence of BRCA1 or BRCA2 mutations influences risk, not necessarily prognosis or treatment success.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is preparing a client with breast cancer for BRCA1 and BRCA2 genetic testing. Which pathophysiological process should the nurse use to support client teaching?

Correct Answer is C

Explanation

A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

After receiving report, the nurse can most safely plan to assess which client last?

When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which action should the nurse implement?

Exhibits here The nurse places the client on a cardiorespiratory monitor and places the nasal cannula on the client. The nurse then completes an assessment and documents it in the chart. For each body system, click to specify the assessment findings that indicates hypoxia.

Prior to insertion of an indwelling urinary catheter, which client information is most important for the nurse to obtain?