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 C
Explanation
Choice A Reason: Applying a transparent dressing to the drain site is not an appropriate action for the nurse to take, as it may trap moisture and bacteria and increase infection risk.
Choice B Reason: Clamping the tubing when the client ambulates is not an appropriate action for the nurse to take, as it may cause bile accumulation and leakage and increase pressure and pain.
Choice C Reason: Placing the client into Fowler's position is an appropriate action for the nurse to take, as it helps to promote drainage and prevent reflux of bile into the liver.
Choice D Reason: Securing the tubing to the client's gown is not an appropriate action for the nurse to take, as it may cause tension and displacement of the drain and increase discomfort and bleeding.
Correct Answer is A
Explanation
Choice A Reason: Urine output 800 mL/hr is a sign of diabetes insipidus, as it indicates that the kidneys are producing large amounts of diluted urine due to the lack of antidiuretic hormone (ADH) or its action.
Choice B Reason: Blood glucose 198 mg/dL is not a sign of diabetes insipidus, but it may indicate diabetes mellitus or hyperglycemia.
Choice C Reason: Serum sodium 145 mEq/L is not a sign of diabetes insipidus, but it is within the normal range (135-145 mEq/L).
Choice D Reason: Urine specific gravity 1.028 is not a sign of diabetes insipidus, but it indicates concentrated urine due to dehydration or other causes.
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