Complete the following sentence by using the list of options.
The nurse should first anticipate the need to
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Rationale:
• Obtain IV access is the first priority because the client is showing signs of hypovolemic shock low blood pressure (76/45 mm Hg), tachycardia (HR 121/min), pale mucous membranes, and diaphoresis likely due to GI bleeding. Immediate vascular access is necessary for resuscitation and fluid administration.
• Call the surgical suite to notify that the client is arriving STAT would delay essential stabilization. Transporting an unstable client without securing IV access and fluid resuscitation could worsen their condition and is unsafe.
• Place the client in a supine position with feet elevated (modified Trendelenburg) might temporarily improve venous return, but it does not address the underlying fluid deficit. It is not a substitute for urgent fluid replacement via IV access.
• Recheck the client's oxygen saturation is not a priority because the client already has a stable oxygen saturation of 98% on room air. The immediate threat is circulatory collapse, not hypoxia.
• Prepare to administer IV fluids follows IV access to treat hypotension and restore circulating volume. IV fluids help stabilize hemodynamics while awaiting further interventions like endoscopy or blood transfusion if needed.
• Transport the client for endoscopy is inappropriate at this moment because the client is hemodynamically unstable. Endoscopy is important but must be delayed until the client is stabilized.
• Check the ECG may be useful if cardiac concerns arise due to hypotension or tachycardia, but it does not take precedence over immediate circulatory support in this scenario.
• Check arterial blood gases would not provide data that immediately changes the management. The client's O2 saturation is normal, and ABGs are not needed to diagnose or treat hypovolemic shock due to GI bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Preeclampsia: Methylergonovine causes vasoconstriction and increases blood pressure, which can be dangerous in clients with preeclampsia. Administering this medication in such cases can elevate the risk of stroke or seizure due to worsening hypertension.
B. An allergy to penicillin: Methylergonovine is not a penicillin-based medication, so a penicillin allergy does not present a known contraindication or concern. Caution is unnecessary unless there is a known allergy to ergot alkaloids.
C. Gestational diabetes mellitus: Methylergonovine does not significantly impact blood glucose levels or insulin sensitivity. Therefore, it can be used safely in clients with gestational diabetes when indicated for hemorrhage control.
D. Cholelithiasis: There is no direct interaction or exacerbation of gallbladder disease with methylergonovine. The medication primarily acts on uterine smooth muscle and vascular tone, not on the biliary system.
Correct Answer is D
Explanation
Rationale:
A. Shortness of breath when climbing stairs: Mild dyspnea is common in the third trimester due to the upward displacement of the diaphragm by the enlarging uterus. This is typically not a concerning sign unless it occurs at rest or is accompanied by other symptoms like chest pain.
B. Periodic numbness of the fingers: Numbness or tingling in the hands and fingers during pregnancy can be caused by carpal tunnel syndrome due to fluid retention. While uncomfortable, it is a benign and relatively common symptom that usually resolves postpartum.
C. Leukorrhea: Leukorrhea, or increased vaginal discharge, is a normal finding in late pregnancy. It helps prevent ascending infections and is only concerning if it becomes foul-smelling, itchy, or changes in color, which could indicate infection.
D. Blurred vision: Blurred vision during the third trimester can be a sign of pregnancy-induced hypertension or preeclampsia. It may indicate cerebral involvement or elevated blood pressure and requires immediate evaluation by the healthcare provider.
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