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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 D

Explanation

A. Sodium phosphate is commonly used as a bowel prep before a colonoscopy, and there is no immediate concern in this situation unless the client is showing signs of dehydration or electrolyte imbalances.
B. A positive Mantoux test induration indicates exposure to tuberculosis, which should be further evaluated, but it is not immediately urgent.
C. An increase in urinary frequency while taking bumetanide (a diuretic) is expected and should be monitored, but it is not a cause for alarm unless accompanied by other signs of dehydration or electrolyte imbalance.
D. Warfarin and breastfeeding require careful monitoring, as warfarin can pass into breast milk and affect the infant. The nurse should follow up on this situation to ensure the safety of both the mother and infant.

Correct Answer is B

Explanation

A. Infusing vancomycin at a faster rate could increase the risk of infusion-related reactions such as "red man syndrome" and is not recommended.
B. For scheduled non-time-critical medications (which includes most routine intravenous antibiotics), standard acute care guidelines allow a 1-hour window for administration: up to 30 minutes before or up to 30 minutes after the scheduled time. Therefore, telling the client that the medication can be started 30 minutes early is the only statement that falls safely within this established clinical grace period.
C. Waiting up to 2 hours after the scheduled time violates standard safety protocols. Delaying an antibiotic by 2 hours can cause the drug's therapeutic serum concentration to drop below the minimum inhibitory concentration (MIC), potentially reducing its effectiveness against the infection.
D. Adjusting the time and schedule to the client's convenience may not ensure that the medication is administered effectively and within the proper timeframe.

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