Exhibits
Review H and P, nurse's note, laboratory results, and flow sheet.
Complete thee diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
- Small intestinal obstruction is indicated by the client’s abdominal distension, absence of bowel sounds, refusal to eat, and episodes of vomiting. The laboratory results show metabolic acidosis (HCO3 of 16 mEq), which can be associated with a bowel obstruction.
- Placing a nasogastric tube helps decompress the stomach and relieve pressure caused by the obstruction, while giving IV fluids helps to prevent dehydration and electrolyte imbalances that can occur with vomiting and obstruction.
- Monitoring signs and symptoms of dehydration is crucial as the client has been vomiting and may not be able to maintain adequate fluid intake. Monitoring temperature is also essential to detect any signs of infection or complications related to the obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ketorolac is an anti-inflammatory medication that is not specifically contraindicated in the case of a chemical burn, but care should be taken.
B. There is no specific contraindication for ketorolac related to radiation exposure.
C. Ketorolac can be used in the presence of a foreign body, but caution is needed based on the type of injury.
D. A corneal abrasion is a condition where ketorolac may be contraindicated due to the risk of delayed healing; thus, reviewing the medical record for any history of corneal abrasion is crucial before administration.
Correct Answer is B
Explanation
A. While attaching humidification can be beneficial for patients with respiratory issues, the immediate priority is to assess the client's oxygenation status.
B. Obtaining a pulse oximetry reading is crucial to determine the client's oxygen saturation level and guide further interventions.
C. Coaching through huff coughing is helpful, but it is more important to first assess oxygenation to understand the severity of the dyspnea.
D. Providing a nebulizer treatment can be an important intervention, but it should follow the assessment of the client's oxygen levels to determine if immediate treatment is necessary.
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