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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

A.

Start an IV bolus of lactated Ringer's solution.

B.

Stay with the client for the first 15 min of the transfusion.

C.

Obtain the first unit of packed RBCs from the blood bank.

D.

Document the blood product transfusion in the client's medical record.

E.

Titrate the rate of infusion to maintain the client's blood pressure at least 90/60 mm Hg.

Answer and Explanation

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.


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Related Questions

Correct Answer is B

Explanation

A. Incorrect. A client receiving heparin for deep-vein thrombosis should not be discharged early.
B. Correct. This client is the most appropriate candidate for early discharge in anticipation of multiple client admissions. Vertebroplasty is a minimally invasive procedure that typically requires only a short hospital stay. The client is likely stable at 1 day post-procedure and can be discharged with appropriate follow-up care.
C. Incorrect. A client with COPD and a respiratory rate of 44/min needs immediate attention, not early discharge.
D. Incorrect. This client is stable for discharge, as sealed radiation implants typically do not require hospitalization after a certain point, assuming they are stable and able to manage their care at home. Discharging this client can help free up resources for incoming patients, provided they have appropriate support at home.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

Pyrexia, also known as fever, refers to an elevated body temperature that is above the normal range. The normal body temperature is typically around 37°C (98.6°F), and a temperature of 38.4°C (101.1°F) indicates a fever.

Alternative Choices:

1. "tachycardia" due to "heart rate of 92/min"

  • Incorrect. Tachycardia refers to an abnormally high heart rate, usually above 100 beats per minute (bpm) in adults. A heart rate of 92/min is within normal limits and does not qualify as tachycardia.

2. "hypertension" due to "blood pressure of 130/78 mm Hg"

  • Incorrect. Hypertension is defined as having a blood pressure reading consistently above 140/90 mm Hg. The reading of 130/78 mm Hg falls into the elevated category but does not reach the threshold for hypertension.

3. "respiratory distress" due to "respiratory rate of 18/min"

  • Incorrect. A respiratory rate of 18 breaths per minute is considered normal for adults, so this finding does not indicate respiratory distress.

4. "obesity" due to "current BMI of 29.9"

  • Partially correct. A BMI of 29.9 places the client in the "overweight" category, just below the threshold for obesity (BMI of 30 or higher). However, the presence of pyrexia is the more immediate clinical concern based on the provided vital signs.

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