The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?
Urine output of 30 mL/hr
Blood pressure is 90/40
IV site is infiltrated
Oral fluid intake of 100 mL for 8 hours
The Correct Answer is B
Choice A reason: Urine output of 30 mL/hr is concerning as it is on the lower end of normal and can indicate dehydration or impaired renal function. However, in this context, it is less immediately alarming compared to severely low blood pressure.
Choice B reason: Blood pressure of 90/40 is critically low and indicates hypotension, which can be a sign of severe dehydration or shock, especially in a patient with ongoing nausea and vomiting. This requires immediate attention and intervention to stabilize the patient and prevent further complications.
Choice C reason: An infiltrated IV site is a problem that needs to be addressed to ensure proper administration of fluids and medications. However, it is not as immediately life-threatening as hypotension.
Choice D reason: Oral fluid intake of 100 mL for 8 hours is inadequate, suggesting that the patient may be dehydrated. While concerning, it is not as acutely critical as low blood pressure, which directly affects perfusion and organ function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Administering antiemetics before chemotherapy is an effective intervention to help manage Sarah's nausea. Antiemetics can prevent or reduce the severity of nausea and vomiting associated with chemotherapy, making it easier for patients to tolerate treatment and maintain their nutritional status.
Choice B reason: Encouraging carbonated beverages is not a recommended intervention for managing nausea. Carbonated beverages can sometimes worsen nausea due to their acidity and carbonation.
Choice C reason: Recommending three large meals and two small snacks daily is not the best approach for managing nausea. Smaller, more frequent meals are generally more effective in preventing nausea and ensuring adequate calorie intake. Large meals can be overwhelming and may exacerbate nausea.
Correct Answer is A
Explanation
Choice A reason: Contacting the health care provider is the most appropriate action because a change in the Doppler sound may indicate a potential complication, such as graft occlusion or compromised blood flow. Immediate assessment and intervention by the health care provider are essential to prevent further complications and ensure the patient's safety.
Choice B reason: Rechecking the pulse in another 30 minutes is not advisable in this situation because it could delay necessary medical intervention. Prompt communication with the health care provider is crucial to address the underlying issue and provide timely care.
Choice C reason: Measuring the ankle-brachial index can provide valuable information about blood flow in the lower extremities, but it is not the immediate priority when a significant change in the Doppler sound is detected. Contacting the health care provider for further assessment and instructions takes precedence.
Choice D reason: Administering an oral anticoagulant is not an appropriate action without the direct instruction from a health care provider. The nurse must first report the change in the Doppler sound to the provider and follow their specific orders regarding medication and treatment.
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