A client was admitted in the hospital with peptic ulcer disease tells the nurse about having black tarry stools. Which of the following is the most appropriate nursing action?
Instruct the client to increase fluid intake.
Notify the health care provider.
Advise the client to take iron rich foods.
Document the findings.
The Correct Answer is B
Choice A Reason: Instructing the client to increase fluid intake is not the most appropriate nursing action, as it does not address the cause or severity of the bleeding.
Choice B Reason: Notifying the health care provider is the most appropriate nursing action, as it indicates that the client may have a bleeding ulcer that requires immediate evaluation and treatment.
Choice C Reason: Advising the client to take iron rich foods is not the most appropriate nursing action, as it does not prevent or correct anemia or bleeding.
Choice D Reason: Documenting the findings is not the most appropriate nursing action, as it does not initiate any intervention or outcome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason: Redness and warmth of affected extremity are not signs of compartment syndrome, but they may indicate other conditions such as infection or inflammation.
Choice B Reason: Slow capillary refill is a sign of compartment syndrome, as it indicates that there is impaired blood flow to the tissues due to increased pressure within the fascial compartment.
Choice C Reason: Reduced level of consciousness is not a sign of compartment syndrome, but it may indicate other serious conditions such as head injury, stroke, or hypoxia.
Choice D Reason: Pain and bleeding are not specific signs of compartment syndrome, but they may occur due to the fracture or other causes.
Correct Answer is B
Explanation
Choice A Reason: Encouraging the client to cough and deep breathe every two hours, with her neck in a flexed position, is not a priority for a client after a total thyroidectomy, as it may increase the risk of bleeding or damage to the surgical site.
Choice B Reason: Maintaining the client in a Fowler's position, with head neutral supported by pillows, is a priority for a client after a total thyroidectomy, as it helps to reduce swelling and edema, prevent airway obstruction, and promote venous drainage.
Choice C Reason: Maintaining the client in a supine position, with sandbags placed on either side of her head and neck, is not a priority for a client after a total thyroidectomy, as it may impair breathing and circulation, increase pressure on the surgical site, and cause neck stiffness.
Choice D Reason: Encouraging the client to turn head side to side, to promote drainage of oral secretions, is not a priority for a client after a total thyroidectomy, as it may cause pain and discomfort, disrupt the sutures or drains, and increase the risk of infection.
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