The nurse is obtaining the client's vital signs prior to an endoscopy.
Complete the following sentence by using the list of options.
The nurse should first anticipate the need to
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-1":"B"}
The nurse should first anticipate the need to withhold oral intake then assess the client's vital signs.
Given the client’s symptoms of gnawing abdominal pain, dark tarry stools (indicating possible gastrointestinal bleeding), and pain worsened by eating, withholding oral intake is crucial to prevent further irritation or complications, especially before an endoscopic procedure. This helps avoid complications such as aspiration or exacerbating gastrointestinal issues. After ensuring that oral intake is managed appropriately, the nurse should then assess the client's vital signs to monitor for signs of hemodynamic instability or further deterioration, which can provide critical information about the client's current condition and guide further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice A rationale: It’s normal for a 4-year-old child to ask the same questions repeatedly. This is a part of their learning process as they are trying to understand the world around them. They often ask the same questions to reassure themselves about the consistency and predictability of the world. However, this is not a priority issue compared to the other options.
Choice B rationale: While it’s important for children to have a balanced diet, including green vegetables, it’s also common for children to be picky eaters. Parents can introduce new foods gradually and make meal times fun to encourage children to eat a variety of foods. However, this is not a priority issue compared to the other options.
Choice C rationale: Bedwetting is common in children and can be a part of their development. Most children outgrow bedwetting by the time they start school. However, if the child is stressed or has a medical condition, it could lead to bedwetting. While this could be a concern, it’s not the priority issue in this scenario.
Choice D rationale: A change in behavior, such as becoming withdrawn, can be a sign of emotional distress in a child. This could be due to a variety of reasons, including changes in their environment like switching day care providers. This is the priority for the nurse to address as it could indicate that the child is having difficulty adjusting to the new day care, which could impact their emotional well-being.
Correct Answer is A
Explanation
A. Correct. Respiratory syncytial virus (RSV. is primarily spread through respiratory droplets.
Initiating droplet precautions, which include wearing a mask and placing the client in a private room, is appropriate to prevent the spread of the virus.
B. Incorrect. Monitoring the preschooler's urine for protein is not relevant to the care of a client with RSV.
C. Incorrect. Fluconazole is an antifungal medication and is not indicated for the treatment of RSV.
D. Incorrect. Requesting an x-ray of the preschooler's neck is not relevant to the care of a client with RSV.
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