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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Correct Answer is ["A","C"]

Explanation

Choice A reason: Performing assisted coughing is crucial for patients with spinal cord injuries who may have weakened respiratory muscles. Assisted coughing helps clear secretions from the airways, thus improving oxygenation and preventing respiratory complications like pneumonia.

Choice B reason: Administering steroids is not a primary intervention for addressing hypoxia in patients with spinal cord injuries. Steroids can be used to reduce inflammation, but they do not directly improve respiratory status or oxygenation.

Choice C reason: Administering oxygen is a direct and effective intervention for managing hypoxia. Supplemental oxygen helps ensure that the patient maintains adequate blood oxygen levels, which is critical for overall tissue perfusion and function.

Choice D reason: Administering antibiotics is not immediately relevant to the treatment of hypoxia unless there is an underlying infection causing or contributing to respiratory distress. Antibiotics are used to treat infections, not directly to improve respiratory status in cases of hypoxia.

A. Administer antiemetics before chemotherapy B. Encourage carbonated beverages C. Recommend three large meals and two small snacks daily to increase calorie intake

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.

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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

The arterial blood gas (ABG) report of a patient with a spinal cord injury indicates hypoxia. Select two interventions the nurse would perform to improve the patient's respiratory status.

Correct Answer is ["A","C"]

Explanation

Correct Answer is A

Explanation

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