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Exhibits

The nurse is obtaining the client's vital signs prior to an endoscopy.

Complete the following sentence by using the list of options.

The nurse should first anticipate the need to

then
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}

The nurse should first anticipate the need to Obtain IV access then Prepare to administer IV fluids.

Rationale

First Anticipated Step: Obtain IV Access:

In a client with hypotension and anemia, immediate IV access is crucial to administer fluids or blood

products to stabilize the client’s condition before the endoscopy. Given the client’s low blood pressure and heart rate, they may need IV fluids (such as saline or Ringer's lactate) to help improve circulation and maintain perfusion. This is essential before proceeding with further interventions like the planned endoscopy.

Second Anticipated Step:

Prepare to administer IV fluids:

The client's low blood pressure and the potential for significant blood loss suggest that IV fluids will be necessary to restore blood volume and improve hemodynamic stability before endoscopy. Normal saline or Lactated Ringer's are commonly used for volume resuscitation in this scenario.


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Related Questions

Correct Answer is B

Explanation

A. Repositioning without assistive devices can place undue strain on both the client and the nurse, especially after a stroke. Assistive devices should be used to maintain safety.
B. It is essential to discuss the client’s preferences and comfort levels to ensure the repositioning
schedule is tailored to their needs.
C. While evaluating the client's ability to help is important, it may not be the priority immediately following a stroke.
D. Raising both side rails may increase the risk of injury or restrict movement. It’s safer to use one side
rail for support when repositioning.

Correct Answer is A

Explanation

A. Dark yellow urine and low urine output (25 mL/hr) may indicate dehydration or decreased fluid intake, so a fluid bolus is indicated to promote kidney perfusion.
B. Continuous bladder irrigation is typically indicated if there is concern about urinary tract obstruction or blood clots, not for low urine output alone.
C. Clamping the catheter can further hinder urine output and is not indicated.
D. A urine culture and sensitivity might be necessary if infection is suspected, but the priority is to address hydration first.

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