A client who had a biliopancreatic diversion procedure (BDP) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
Loose bowel movements.
Occult positive emesis.
Strong foul smelling flatus.
Report of poor night vision.
The Correct Answer is B
B. Occult positive emesis refers to vomiting that occurs without the client's awareness, meaning that the vomitus may not be easily visible or readily apparent. Vomiting can lead to significant fluid loss and dehydration, which is particularly concerning in a client who has undergone a biliopancreatic diversion procedure (BDP).
A. Loose bowel movements may indicate gastrointestinal disturbances or malabsorption issues commonly seen after biliopancreatic diversion procedure (BDP). BDP involves rerouting a significant portion of the small intestine, which can affect digestion and absorption of nutrients and fluids.
C. Strong foul-smelling flatus may indicate bacterial overgrowth or malabsorption issues in the gastrointestinal tract, which can occur after BDP. While foul-smelling flatus can be uncomfortable and indicative of gastrointestinal disturbances, it may not require immediate intervention.
D. Poor night vision may suggest vitamin deficiencies, particularly deficiencies in fat-soluble vitamins such as vitamin A, which can occur after BDP due to reduced absorption of nutrients. While poor night vision should be addressed to prevent long-term complications, it may not pose an immediate threat to the client's health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:This is incorrect because teaching the client to wear a mask, hand wash, and social distance is not the most important action for the nurse to take. These are preventive measures that should be followed by everyone, regardless of their COVID-19 status.
Choice Breason:This is incorrect because explaining to the client to inform others that they may have been potentially exposed in the last 14 days is not the most important action for the nurse to take. This is a moral and social responsibility that should be done as soon as possible, but it does not address the urgent need of isolating the client from potential sources of infection.
Choice Creason:This is correct because isolating the client from other clients, family, and healthcare workers not wearing proper PPE is the most important action for the nurse to take. This is to prevent transmission of COVID-19 to others who may be at risk of severe complications or death.
Choice Dreason:This is incorrect because reporting the COVID-19 result to the local health department according to CDC guidelines is not the most important action for the nurse to take. This is a legal and ethical obligation that should be done after confirming the diagnosis, but it does not have an immediate impact on the client's health or safety.
Correct Answer is ["10"]
Explanation
To determine the mL/hr rate for the regular insulin infusion, we can set up a proportion: 10 units/hr (prescribed rate) = x mL/hr (unknown rate)
Since the IV solution contains 100 units of regular insulin in 100 mL of 0.9% normal saline, we know that each mL of the solution contains 1 unit of regular insulin.
So, if 1 mL contains 1 unit, then x mL contains 10 units. x = 10 mL/hr
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