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 A
Explanation
A. Correct. Leaving steris-trips on until they fall off naturally promotes wound healing and reduces the risk of infection.
B. Incorrect. A high-fat diet is not recommended post-cholecystectomy; a low-fat diet is usually advised to prevent discomfort.
C. Incorrect. Diarrhea is not a common or expected outcome following laparoscopic cholecystectomy.
D. Incorrect. While some postoperative nausea might be expected, it should not persist for several days. Prolonged nausea may require medical attention.
Correct Answer is C
Explanation
A. Elevated blood pressure is not a specific finding associated with diabetic ketoacidosis (DKA..
B. Bounding pulse might be present due to dehydration in DKA, but it's not a defining characteristic.
C. Correct. Fruity breath odor (often described as "fruity" or "acetone-like". is a characteristic sign of DKA due to the presence of ketones in the breath?
D. Clammy skin is not a specific finding associated with DKA.
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