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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 C

Explanation

A. Sinus arrhythmia is typically not life-threatening and does not require immediate assessment unless other symptoms are present.
B. Epidural analgesia can cause some weakness in the lower extremities, but this is a known side effect and not an emergency.
C. Tachypnea, especially with a new onset in a client with a hip fracture, may indicate complications such as a fat embolism or pulmonary embolism, which require immediate assessment.
D. An HbA1c of 7.2% is slightly above the target but is not an immediate concern compared to other acute symptoms.

Correct Answer is B

Explanation

A. While progress notes are important, they do not necessarily promote communication among the entire team.
B. Regular interdisciplinary team meetings ensure that all staff are updated on the client's needs, fostering coordinated care.
C. Swallowing precautions should be communicated to the staff but are not directly related to communication about expressive aphasia or hemiparesis.
D. Noting changes in the treatment plan is important but does not specifically promote communication about the client’s condition across the team.

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