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. Assessing whether the client has a plan for self-harm is a priority in evaluating the immediate risk of suicide. If a plan is present, further assessment and intervention are needed.
B. Incorrect. While having support is important, knowing whether the client has a plan for self-harm takes precedence.
C. Incorrect. While a family history of suicide is a risk factor, it is not as immediate a concern as determining whether the client has a current plan.
D. Incorrect. Assessing the sources of stress is important, but the immediate risk of self-harm takes priority.
Correct Answer is D
Explanation
A. Incorrect. Applying an ice pack to the affected extremity is not recommended for a client with deep vein thrombosis, as it could potentially exacerbate the condition by promoting vasoconstriction.
B. Correct. Administering aspirin for pain relief is an appropriate action for a client with deep vein thrombosis. Aspirin has anti-inflammatory and analgesic properties and can help manage pain associated with thrombosis.
C. Incorrect. Massaging the affected extremity is contraindicated for a client with deep vein thrombosis, as it can dislodge the clot and pose a risk of embolization.
D. Incorrect. Initiating bed rest is not recommended for a client with deep vein thrombosis.
Encouraging early ambulation and mobilization can help prevent complications such as thrombus extension and pulmonary embolism.
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