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
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.
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Related Questions
Correct Answer is D
Explanation
- A: Providing a list of alternative activities may reduce fatigue, but it does not consider the child's interest in swimming, which can be therapeutic and enjoyable for children with Duchenne muscular dystrophy.
- B: While team sports can be good for socialization, they may not be suitable for a child with Duchenne muscular dystrophy due to the progressive muscle weakness associated with the condition, which could lead to increased risk of injury.
- C: At the age of 6, children are capable of understanding basic risks, and it is important to communicate with them appropriately rather than assuming they are too young. Moreover, swimming can be adapted to be safe for children with physical limitations.
- D: Swimming is an excellent activity for children with Duchenne muscular dystrophy because it is low-impact and can help maintain muscle strength and function. With proper supervision and precautions, the risks can be managed, making it a suitable activity for the child to continue.
Correct Answer is B
Explanation
A. Oxygen is less toxic when it is humidified with a hydration source. While humidification can prevent drying of the respiratory mucosa, it does not directly relate to the principle of avoiding high levels of oxygen for extended periods.
B. Avoid administration of oxygen at high levels for extended periods. This is the correct principle. Prolonged exposure to high levels of oxygen can lead to oxygen toxicity, which can cause lung damage. Oxygen therapy should be titrated to maintain adequate oxygenation without exposing the patient to excessive oxygen levels.
C. Increase oxygen rate during sleep to compensate for slower respiratory rate. This statement is incorrect. Oxygen therapy should be adjusted based on the patient's oxygen saturation levels and respiratory status, not solely on sleep patterns.
D. Taking a sedative at bedtime slows respiratory rate, which decreases oxygen needs. While sedatives can depress respiratory rate, leading to decreased oxygen needs, this is not a general principle of oxygen administration. Oxygen therapy should be based on the patient's oxygenation needs rather than medications they are taking.
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