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 C
Explanation
A. Prednisone should generally be taken with food or after a meal to reduce the risk of gastric irritation or ulcer formation. Taking it on an empty stomach can irritate the stomach lining and increase the risk of gastrointestinal side effects, such as gastritis or peptic ulcers.
B. While some medications are best taken at bedtime (such as those with sedative effects), prednisone is a corticosteroid that can affect the body's circadian rhythm and may interfere with sleep. It typically causes insomnia or restlessness, so it’s usually advised to take it in the morning.
C. Prednisone and other corticosteroids can lead to bone loss (osteoporosis) over time, especially with long-term use. One of the side effects of corticosteroid therapy is decreased calcium absorption and bone density loss, making individuals at higher risk for fractures.
D. Prednisone more commonly causes weight gain rather than weight loss. Corticosteroids increase appetite and can lead to fluid retention, both of which can result in weight gain. Additionally, prednisone can cause redistribution of fat, often leading to characteristic side effects like "moon face" or increased abdominal fat.
B. Incorrect. Prednisone is often prescribed as a single daily dose in the morning to coincide with the body's natural cortisol release.
C. Incorrect. While calcium supplementation might be necessary for some individuals on long-term prednisone therapy, it is not a primary instruction related to taking prednisone.
D. Correct. Monitoring for weight loss is important due to the potential for weight changes (both weight gain and weight loss) as a result of prednisone's effects on metabolism and appetite.
Correct Answer is B
Explanation
A. Incorrect. Suggesting finding alternative remedies through an online support group may not provide accurate or safe information.
B. Correct. This response acknowledges the client's interest and offers to provide guidance in selecting a safe alternative practitioner. It's important to ensure that any alternative therapies are safe and evidence-based.
C. Incorrect. While it's important to respect the client's personal beliefs, the nurse should also ensure that the chosen therapies are safe and effective.
D. Incorrect. Waiting for the provider to suggest alternative therapies may delay the client's access to safe and effective treatments.
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