The nurse is in the G unit is assessing a patient after receiving the change of shift SBAR report. What assessment findings will the nurse report immediately to the provider?

The patient who is having white milky liquid stools immediately after a barium enema.

The patient with irritable bowel syndrome (IBS) who has not had a bowel movement for three days.

The patient diagnosed with ulcerative colitis with a temperature of 101°F and abdominal distention.

The patient receiving Total Parenteral Nutrition (TPN) whose blood glucose level is 225 mg/dL.

Answer and Explanation

The Correct Answer is C

Choice A reason: White milky liquid stools immediately after a barium enema are not uncommon and are typically due to the passage of barium. This finding does not usually require immediate reporting unless there are other concerning symptoms.

Choice B reason: Not having a bowel movement for three days in a patient with irritable bowel syndrome (IBS) can be uncomfortable but is not typically an emergency. Management can be addressed through dietary and medication adjustments rather than immediate reporting.

Choice C reason: A temperature of 101°F and abdominal distention in a patient diagnosed with ulcerative colitis is concerning and should be reported immediately. These symptoms can indicate a serious complication such as toxic megacolon, perforation, or severe infection, which require prompt medical intervention.

Choice D reason: A blood glucose level of 225 mg/dL in a patient receiving Total Parenteral Nutrition (TPN) is elevated but not necessarily an emergency. Elevated blood glucose levels are a common side effect of TPN and can be managed through adjustments in insulin or TPN composition.

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Correct Answer is B

Explanation

Choice A reason: Administering a platelet transfusion immediately is not indicated for a platelet count of 45,000/mm³. While this is below the normal range, it is not critically low. Platelet transfusions are typically reserved for patients with life-threatening bleeding or extremely low platelet counts.

Choice B reason: Monitoring the patient for signs of bleeding and educating about bleeding precautions is the appropriate intervention. Patients with thrombocytopenia are at an increased risk of bleeding, and it is essential to educate them on how to minimize this risk, such as avoiding activities that can cause injury, using a soft toothbrush, and avoiding over-the-counter medications that can affect platelet function.

Choice C reason: Administering aspirin to reduce the risk of clot formation is incorrect. Aspirin is an antiplatelet agent that can increase the risk of bleeding in patients with thrombocytopenia. It should be avoided unless specifically prescribed for another condition with close monitoring.

Choice D reason: Encouraging the patient to engage in regular physical exercise to improve circulation is not appropriate in this context. While physical activity is generally beneficial, it should be done with caution in patients with thrombocytopenia to avoid injury and bleeding. The focus should be on safety and bleeding precautions.

A. Encourage the patient to rest in bed for most of the day. B. Administer a high-protein diet including caffeinated beverages to increase energy levels. C. Assist the patient with activities of daily living (ADLs) and encourage frequent rest periods. D. Provide supplemental oxygen via face mask during vigorous exercises.

Correct Answer is C

Explanation

Choice A reason: Encouraging the patient to rest in bed for most of the day may lead to further deconditioning and muscle weakness. While rest is important, balancing activity and rest is more beneficial for managing fatigue in chronic anemia.

Choice B reason: Administering a high-protein diet including caffeinated beverages to increase energy levels is not recommended. While a high-protein diet can support energy and muscle strength, caffeine may cause jitteriness and disrupt sleep, which can exacerbate fatigue.

Choice C reason: Assisting the patient with ADLs and encouraging frequent rest periods is appropriate for managing fatigue, weakness, and activity intolerance in chronic anemia. This approach helps the patient conserve energy while maintaining some level of activity to prevent deconditioning.

Choice D reason: Providing supplemental oxygen via face mask during vigorous exercises is not appropriate. Patients with chronic anemia should avoid vigorous exercises that could exacerbate fatigue and weakness. The focus should be on moderate, manageable activities with adequate rest.

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The nurse is in the G unit is assessing a patient after receiving the change of shift SBAR report. What assessment findings will the nurse report immediately to the provider?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient with thrombocytopenia who has a platelet count of 45,000/mm³. What nursing intervention will the nurse implement to manage this condition?

Correct Answer is B

Explanation

The nurse is caring for a patient admitted to the hospital with chronic anemia. The patient reports persistent fatigue, weakness, and activity intolerance. Which intervention will the nurse implement for these manifestations?

Correct Answer is C

Explanation

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