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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A licensed practical nurse (LPN) is capable of performing sterile dressing changes, which is within their scope of practice.
B. An admission assessment requires a registered nurse (RN) to evaluate and formulate a comprehensive care plan, which exceeds the scope of an LPN.
C. Discharge teaching requires the RN’s expertise to provide in-depth education and ensure the patient understands the plan.
D. Completing the Glasgow Coma Scale requires an RN to assess neurological status and make appropriate decisions about care.
Correct Answer is A
Explanation
A. When using crutches, the client should position both hands on the grips with the elbows slightly flexed for proper support and balance.
B. In the three-point gait, the crutches and the injured leg move together, followed by the uninjured leg. The stronger leg does not move first.
C. The client should not lean on the axillary crutch pads as it can cause nerve damage. Body weight should be supported through the hands and arms.
D. When going up stairs, the uninjured leg should move first, followed by the crutches and the affected leg.
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