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.

Exhibits

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

Answer and Explanation

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

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Correct Answer is B

Explanation

A. I should avoid alcohol completely to prevent another episode of pancreatitis: This is correct advice, as alcohol is a common cause of pancreatitis and should be avoided.

B. I can resume my high-fat diet once my symptoms improve. A high-fat diet can trigger another episode of pancreatitis, as fat stimulates pancreatic enzymes that can exacerbate the condition. The patient should follow a low-fat diet.

C. I should take my prescribed medications as directed to manage my symptoms: This statement is appropriate and reflects adherence to the treatment plan.

D. I need to follow up with my healthcare provider regularly to monitor my condition: This is also correct, as regular monitoring is essential to managing pancreatitis.

A. Flush the T-tube with sterile water every 6 hours to maintain patency. B. Clamp the T-tube for 12 hours each day to reduce bile flow C. Secure the T-tube to the patient's gown to prevent accidental dislodgement. D. Maintain the drainage bag below the level of the abdomen to promote gravity drainage.

Correct Answer is D

Explanation

A. Flush the T-tube with sterile water every 6 hours to maintain patency: T-tubes are generally not flushed unless prescribed by a healthcare provider because flushing can introduce bacteria and cause complications. Patency is typically maintained by gravity drainage alone.

B. Clamp the T-tube for 12 hours each day to reduce bile flow: Clamping the T-tube is not routinely recommended for such long periods unless directed by the healthcare provider. Clamping is usually done gradually, often for 1-2 hours, to assess the patient’s ability to tolerate bile drainage naturally before tube removal.

C. Secure the T-tube to the patient's gown to prevent accidental dislodgement: While securing the T-tube prevents accidental dislodgement, the tube should be taped to the skin rather than the gown, as attaching it to clothing can increase the risk of unintentional dislodgement with movement.

D. Maintain the drainage bag below the level of the abdomen to promote gravity drainage. This is the correct answer because positioning the drainage bag below the abdomen allows for gravity to assist in the flow of bile from the bile duct, preventing backup and promoting proper drainage.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with acute pancreatitis is being discharged from the hospital. Which statement made by the patient indicates a need for further teaching regarding their discharge instructions?

Correct Answer is B

Explanation

A patient is recovering from a common bile duct exploration and has a T-tube drain in place. As the nurse, which action is most appropriate to ensure proper function and patient safety?

Correct Answer is D

Explanation

A patient with a history of ulcerative colitis presents to the clinic with complaints of fatigue, dizziness, and pallor. Upon further assessment, you suspect chronic blood loss. Which potential complication is most likely contributing to these symptoms?

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A patient with chronic kidney disease (CKD) is being evaluated for medication management. Which of the following medications should be avoided due to its potential nephrotoxic effects?

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