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
A. Incorrect. Encouraging the client to watch television might not provide the calming presence and support needed during a panic attack.
B. Correct. Sitting with the client and providing a sense of security can help them feel more grounded and supported during the panic attack.
C. Incorrect. Atomoxetine is not typically used to treat acute panic attacks. It's a medication used for attention deficit hyperactivity disorder (ADHD).
D. Incorrect. Teaching the client how to meditate might be beneficial in the long term, but during an acute panic attack, the client may not be receptive to learning new techniques.
Correct Answer is B
Explanation
Choice B rationale:
Teaching the client to tighten a muscle group, release the tension, and then move to the next one is a technique used in progressive muscle relaxation (PMR) PMR is a stress management technique that involves tensing and relaxing different muscle groups to reduce muscle tension and promote relaxation. This method helps individuals become more aware of the sensations associated with muscle tension and relaxation, making it an effective strategy for managing anxiety and stress.
Choice A rationale:
Thinking about a positive outcome to a stressful situation is a cognitive-behavioral technique that can help shift the client's focus from negative thoughts to positive ones. While this technique can be beneficial, it does not specifically pertain to progressive relaxation as described in choice B.
Choice C rationale:
Picturing taking the stress and pushing it out of the feet is a visualization technique, which can be helpful for some individuals in managing stress. However, it is not a component of progressive relaxation as described in choice B.
Choice D rationale:
Focusing on a pleasant memory and expressing emotions in writing is a form of journaling or expressive writing, which can be a therapeutic technique for managing emotions and stress. While it can be a helpful strategy, it is not the same as progressive relaxation involving muscle tension and release.
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