A 55-year-old male patient presents to the emergency department with complaints of acute gastrointestinal (GI) bleeding. The patient reports passing black, tarry stools and experiencing dizziness and weakness. On physical examination, he is pale and diaphoretic.
Which of the following are the most appropriate initial nursing interventions for this patient? (Select all that apply)
Administer IV fluids
Prepare for possible blood transfusion
Monitor hemoglobin and hematocrit levels
Administer a proton pump inhibitor (PPI)
Administer oral iron supplements to address anemia
Correct Answer : A,B,C,D
A. Administer IV fluids: The patient is hypotensive (blood pressure 88/54 mmHg) and tachycardic (heart rate 115 bpm), indicating possible hypovolemic shock due to blood loss. Administering IV fluids will help to stabilize blood pressure.
B. Prepare for possible blood transfusion: The patient's hemoglobin level is critically low (6.5 g/dL), indicating significant blood loss and severe anemia. Preparing for a blood transfusion is crucial to correct the anemia.
C. Monitor hemoglobin and hematocrit levels: Continuous monitoring of hemoglobin and hematocrit levels is vital to assess the severity of the patient's anemia and response to treatment, guiding further interventions.
D. Administer a proton pump inhibitor (PPI): PPIs can help reduce gastric acid secretion, which may help control bleeding from peptic ulcers, a common cause of upper GI bleeding.
E. Administer oral iron supplements to address anemia: Oral iron supplements are typically used for long-term management of iron deficiency anemia but are not effective for immediate correction of severe anemia, particularly in an acute setting with ongoing blood loss.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. I should eat only plant-based proteins to manage my symptoms: While plant-based proteins may be a part of the diet, limiting protein intake solely to plant-based sources is not necessary, and animal proteins like chicken and fish are recommended for tissue repair.
B. I should avoid all sources of protein to prevent flare-ups: Protein is necessary for healing and should not be completely avoided.
C. I should follow a low-protein diet to reduce intestinal inflammation: There is no evidence that a low-protein diet helps reduce inflammation in Crohn's disease. High-protein intake is beneficial.
D. I should include high-protein foods like chicken and fish in my diet. During active inflammation in Crohn's disease, a high-protein diet is important for healing and maintaining muscle mass, especially since malabsorption can be a concern.
Correct Answer is D
Explanation
A. Encourage the patient to use an alcohol-based mouthwash to clean the oral cavity:
Alcohol-based mouthwashes can irritate the oral mucosa and worsen the pain of stomatitis. Instead, non-alcoholic, soothing mouth rinses are recommended.
B. Advise the patient to avoid all oral intake until the ulcers heal completely: Patients still need proper nutrition, and complete avoidance of food can lead to malnutrition. Soft, non-irritating foods are encouraged rather than full avoidance.
C. Suggest the patient brush their teeth vigorously to remove any bacteria from the mouth: Vigorous brushing can worsen oral ulcers and lead to further pain and bleeding. A gentle, soft-bristle toothbrush should be recommended.
D. Recommend the patient to consume soft, non-irritating foods and avoid acidic or spicy foods.
Consuming soft, bland, non-irritating foods and avoiding acidic or spicy foods helps reduce discomfort and prevent further irritation of oral ulcers, which is essential in managing stomatitis.
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