The nurse reviews the entries in the medical record.
Admission Assessment 0900:
Client reports, "I'm bloated and my stomach hurts." History of prior illness: Client reports a 3-week history of gnawing abdominal pain. Client states, "It's a burning sensation that radiates to my back. I think I've lost a little weight too." Reports one episode of dark, tarry stool. No vomiting. Client reports pain is worse about 1 hr after eating a meal. Past medical history: Osteoarthritis
Social history: Recently divorced, drinks in moderation (3 to 4 drinks per week), smokes tobacco
Current medications:
Ibuprofen 800 mg three times daily PRN arthritis pain Physical Examination:
General: client appears uncomfortable, diaphoretic
Head, ears, eyes, nose, and throat (HEENT): oropharynx clear, mucous membranes moist and pale
Respiratory: bilateral breath sounds clear
Gastrointestinal: epigastric tenderness to palpation, no rebound tenderness or guarding Neurological: oriented x 3 (person, place, and time)
The nurse is ready to begin. For each potential nursing action, specify if the action is indicated or not indicated for the client.
Nursing Actions
Start an IV bolus of lactated Ringer's solution.
Stay with the client for the first 15 min of the transfusion.
Obtain the first unit of packed RBCs from the blood bank.
Document the blood product transfusion in the client's medical record.
Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"B"}}
A. Start an IV bolus of lactated Ringer's solution: Not Indicated
- The client's medical record does not indicate a need for fluid resuscitation or immediate volume replacement.
B. Stay with the client for the first 15 min of the transfusion: Not Indicated
- There is no mention of a blood transfusion in the provided information. Therefore, staying with the client during a transfusion is not relevant.
C. Obtain the first unit of packed RBCs from the blood bank: Not Indicated
- There is no indication of a need for a blood transfusion in the client's assessment findings.
D. Document the blood product transfusion in the client's medical record: Not Indicated
- Since there is no indication of a blood transfusion, documenting a transfusion is not relevant.
E. Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg: Not Indicated
- While it's important to monitor and maintain the client's blood pressure, the provided information does not suggest that the client's blood pressure is significantly low (90/60 mm Hg) or that they are receiving any infusions that need titration for blood pressure management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice B rationale:
Flumazenil is a selective antagonist for the benzodiazepine receptor and is used as an antidote for benzodiazepine toxicity. It competitively inhibits the effects of benzodiazepines by binding to the same receptor sites in the central nervous system. Flumazenil can rapidly reverse the sedative and respiratory-depressant effects of benzodiazepine overdose, making it the appropriate choice in this scenario.
Choice A rationale:
Atropine is an anticholinergic medication that is used to treat bradycardia and certain types of heart block. It has no specific antidote effects for benzodiazepine toxicity and would not be the appropriate choice in this situation.
Choice C rationale:
Activated charcoal is used in the management of certain types of poisonings by adsorbing the toxic substance in the gastrointestinal tract, preventing its absorption into the bloodstream. However, it is not effective for benzodiazepine toxicity, which primarily affects the central nervous system and not the gastrointestinal tract.
Choice D rationale:
Naloxone is an opioid receptor antagonist used to reverse opioid overdose. It has no specific effects on benzodiazepine toxicity and would not be the appropriate choice in this case.
Correct Answer is D
Explanation
A. Incorrect. Providing oral hygiene care is important but not the first priority after a client has vomited
B. Incorrect. While administering an antiemetic medication might be considered, providing oral hygiene care to the client is the immediate priority.
C. Incorrect. Replacing the NG tube is not typically the first action to take after a client vomits. Addressing oral hygiene and assessing the client's condition comes first.
D. Correct. Evaluating the functioning of the suction device is important as it helps to prevent aspiration of contents.
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