A client is assessed with abdominal tenderness and bright red blood in their stool. Which action should the nurse take first?
Administer an oral stool softener
Instruct the client to avoid foods with red dyes
Assess the client’s hydration status
Place a pillow under the client's knees
The Correct Answer is C
Reasoning:
Hematochezia, or the passage of bright red blood per rectum, indicates an active lower gastrointestinal bleed that can lead to hemodynamic instability. The nurse's first priority in any situation involving active bleeding is to assess for signs of hypovolemic shock and compensatory physiological changes to ensure the patient's immediate safety.
A. Administering a stool softener is inappropriate and potentially dangerous in the presence of an active gastrointestinal bleed and abdominal tenderness. Stool softeners are used for constipation management, not for acute hemorrhage. Furthermore, giving anything orally (PO) is contraindicated if the patient may require emergency surgery or an endoscopy.
B. While certain red dyes or foods (like beets) can mimic the appearance of blood in the stool, the presence of abdominal tenderness strongly suggests a pathological process rather than a dietary cause. Instructing the client on diet is a low-priority teaching intervention that ignores the immediate clinical risk of hemorrhage.
C. Assessing hydration and hemodynamic status is the priority action. This includes checking the blood pressure for hypotension, the heart rate for tachycardia, and assessing skin turgor and mucous membranes. This data allows the nurse to determine if the client is losing enough blood to compromise systemic perfusion and oxygenation.
D. Placing a pillow under the client's knees is a comfort measure that may actually be contraindicated in some abdominal conditions as it can increase the risk of deep vein thrombosis by impeding venous return. It does nothing to address the physiological emergency of an active gastrointestinal bleed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Reasoning:
Subjective data encompasses the client's personal sensory experiences and perceptions that cannot be independently measured or observed by the healthcare provider. This information, often referred to as symptoms or verbalized complaints, provides critical context for the diagnostic process, particularly in identifying conditions like intermittent claudication or neuropathic distress that occur during physical exertion.
A. Objective data consists of findings that can be seen, heard, felt, or measured by the nurse, such as a rash, a blood pressure reading, or a laboratory value. Since "burning pain" is an internal sensation that only the client can feel, it does not meet the criteria for objective evidence.
B. Documented findings is a broad term that refers to any information recorded in the medical record. While the nurse will document the client's report, this does not describe the specific nature of the data type itself, which is fundamentally based on the patient's subjective report of discomfort.
C. Subjective data is the correct category for pain because it is based on the client's report. Pain is often called "whatever the experiencing person says it is, existing whenever he says it does." The description of burning and its timing relative to activity are classic examples of subjective clinical data.
D. Physical observation involves the nurse using their senses to assess the patient's physical state. While the nurse might observe the client limping or stopping to rest, the actual sensation of "burning pain" cannot be observed; it must be communicated by the client to the healthcare professional.
Correct Answer is D
Explanation
Reasoning:
The female urethra is anatomically short and located in close proximity to the anal reservoir of bacteria. Proper hygiene techniques are essential to prevent the ascending migration of uropathogens, specifically Escherichia coli, which is the most frequent causative agent of community-acquired cystitis and related urinary tract infections.
A. Drinking apple cider vinegar is not a standard, evidence-based recommendation for UTI prevention. While some believe it alters urinary pH, there is insufficient clinical evidence to support this as a primary preventative measure. However, it is not a dangerous practice compared to improper hygiene techniques.
B. Emptying the bladder regularly and completely is an excellent preventative strategy. Urinary stasis provides a medium for bacterial proliferation. By voiding frequently, the patient mechanically flushes bacteria out of the urinary tract, thereby reducing the colonization of the bladder mucosa and the risk of infection.
C. Drinking 2 L of fluid each day ensures adequate urine production and regular flushing of the urinary system. Proper hydration dilutes the urine and decreases the concentration of bacteria. This statement indicates that the client understands the importance of fluid intake in maintaining urinary tract health.
D. Wiping from back to front is an incorrect technique that indicates a need for further teaching. This action moves fecal contaminants and bacteria from the anal region toward the urethral opening, significantly increasing the risk of infection. The correct technique is wiping from front to back.
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