The nurse is assessing a client with peptic ulcer disease (PUD). Which finding, if observed by the nurse, would require immediate follow-up?
Low urine output.
Vomiting after a meal.
Blood in the stool.
Abdominal discomfort.
The Correct Answer is C
Choice A rationale
Low urine output could be due to dehydration, medication effects, or stress. While it warrants further assessment, it is not typically associated with immediate life-threatening complications in the context of PUD.
Choice B rationale
Vomiting after a meal can occur in PUD due to delayed gastric emptying or irritation. However, it does not immediately indicate a complication requiring urgent follow-up unless accompanied by other symptoms such as severe pain or hematemesis.
Choice C rationale
Blood in the stool may indicate gastrointestinal bleeding, a serious complication of PUD. This finding requires immediate evaluation to determine the source and extent of bleeding, as it can lead to hypovolemic shock if untreated.
Choice D rationale
Abdominal discomfort is common in PUD due to gastric irritation or acid-related issues. While it requires management, it does not typically signal an urgent complication unless associated with other alarming symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding.
Choice B rationale
Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia.
Choice C rationale
Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately.
Choice D rationale
A temperature of 96.5°F (35.8°C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.
Correct Answer is A
Explanation
Choice A rationale
Contact isolation prevents the transmission of Clostridium difficile spores, a significant source of nosocomial infections. Private rooms reduce cross-contamination risks.
Choice B rationale
Antidiarrheal use is contraindicated in Clostridium difficile infection as it may worsen colitis by retaining toxins. Prompt stool elimination is vital.
Choice C rationale
Antibiotics are used to treat Clostridium difficile but educating the patient about antibiotic cessation is inappropriate as their use is essential for infection control.
Choice D rationale
Stool softeners are unnecessary since diarrhea is already present, and further softening may exacerbate fluid and electrolyte loss.
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