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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. For the next 24 hours, notify the nurse when the bladder is full, and the nurse will collect
catheterized specimens: This instruction is incorrect for a 24-hour urine collection. Catheterized specimens are not typically used for creatinine clearance tests, and the nurse should not be notified when the bladder is full.
B. Urinate immediately into a urinal, and the lab will collect the specimen every 6 hours for the next 24 hours: This instruction is incorrect for a 24-hour urine collection. Creatinine clearance
tests require collection of all urine produced over a 24-hour period, not just specimens at specific intervals.
C. Urinate at a specified time, discard this urine, and collect all subsequent urine during the next 24 hours: This is the correct instruction for a 24-hour urine collection. The client should begin by discarding the first voided urine and then collect all subsequent urine produced over the next 24 hours, including the urine from the specified time.
D. Cleanse around the meatus, discard the first portion of voiding, and collect the rest in a sterile bottle: This instruction is not appropriate for a 24-hour urine collection. It describes a procedure for collecting a clean-catch urine sample, which is different from a 24-hour urine collection for creatinine clearance.
Correct Answer is C
Explanation
A. This instruction is incorrect because it suggests collecting catheterized specimens, which is not necessary for a creatinine clearance test. Catheterization may increase the risk of contamination and is not typically performed for this test.
B. This instruction is incorrect because it does not involve the collection of a complete 24-hour urine specimen. Collecting specimens every 6 hours would not provide an accurate measurement of creatinine clearance over a 24-hour period.
C. This instruction is correct. For a 24-hour urine collection, the client should urinate at a specified time to start the collection period, discard this urine, and then collect all subsequent urine produced over the next 24 hours. This ensures that the entire 24-hour period is captured for analysis.
D. This instruction is incorrect because it does not involve the collection of all urine produced over a 24-hour period. Additionally, discarding the first portion of voiding is not necessary for a creatinine clearance test and may lead to inaccurate results.
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