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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is ["A","D","F"]

Explanation

Choice A reason: An oxygen mask is essential for providing supplemental oxygen to the patient, especially if they experience respiratory distress or decreased oxygen saturation following a seizure. Ensuring adequate oxygenation is a priority in post-seizure care.

Choice B reason: A nasogastric tube may be used in specific situations for feeding or medication administration, but it is not routinely necessary for all patients treated for status epilepticus.

Choice C reason: A urinary catheter is used for managing urinary output, particularly in patients with retention or incontinence issues, but it is not immediately required for all patients post-status epilepticus.

Choice D reason: Suction set-up is necessary for maintaining the patient's airway and preventing aspiration, particularly if the patient has excessive secretions or vomits after a seizure. Suction equipment allows the nurse to quickly clear the airway and ensure the patient can breathe effectively.

Choice E reason: Tongue blades are not recommended for seizure management as they can cause injury. Historically, there was a misconception about using tongue blades to prevent tongue biting during seizures, but this practice is now discouraged due to the risk of oral injury.

Choice F reason: Side rail pads are important for protecting the patient from injury during potential future seizures. Padded side rails help prevent trauma from hitting the bed rails during convulsions and provide a safer environment for the patient.

A. Improve public transportation to the clinic B. Obtain low-cost medications for clinic patients C. Teach clinic staff about cultural health beliefs D. Update equipment and supplies at the clinic

Correct Answer is C

Explanation

Choice A reason: Improving public transportation to the clinic would indeed make it easier for residents to access healthcare services. However, this strategy alone does not directly address the cultural and specific health needs of the Hispanic community.

Choice B reason: Obtaining low-cost medications for clinic patients can alleviate some financial burdens and improve access to necessary treatments. While this is beneficial, it does not tackle the root of health disparities related to cultural differences and health beliefs.

Choice C reason: Teaching clinic staff about cultural health beliefs is crucial for reducing health care disparities and promoting health equity. Understanding the cultural background, health beliefs, and practices of the Hispanic community allows healthcare providers to deliver more culturally competent and patient-centered care, building trust and improving health outcomes.

Choice D reason: Updating equipment and supplies at the clinic can enhance the quality of care provided. However, without addressing the cultural competency of the healthcare staff, this strategy does not directly impact health equity or reduce disparities specific to the Hispanic community.

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The nurse is caring for a patient who has nausea and vomiting. Which assessment data should be of most concern to the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has been treated for status epilepticus in the emergency department will be transferred to the medical nursing unit. Which equipment should the nurse have available in the patient's assigned room? (Select all that apply)

Correct Answer is ["A","D","F"]

Explanation

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Correct Answer is C

Explanation

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