A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?

Administer an antacid as prescribed

Assess the characteristics of the pain

Check for recent NSAID use

Obtain a stool sample for occult blood

Answer and Explanation

The Correct Answer is B

Choice A reason: Administering an antacid relieves epigastric pain but is premature without assessing pain characteristics. Pain in peptic ulcer disease may indicate complications like perforation, requiring urgent evaluation. Assessment guides whether antacids or other interventions are appropriate, prioritizing patient safety.

Choice B reason: Assessing pain characteristics (e.g., location, intensity, radiation) is the first step, as epigastric pain in peptic ulcer disease may signal complications like bleeding or perforation. This data guides interventions, ensuring timely management of potentially life-threatening conditions, making it the priority action.

Choice C reason: Checking NSAID use identifies ulcer triggers but is secondary to pain assessment. Pain characteristics determine urgency, as severe or radiating pain may indicate perforation, requiring immediate action. Assessment provides critical data before investigating contributing factors like medication history.

Choice D reason: Obtaining a stool sample for occult blood detects gastrointestinal bleeding but is not the first step. Assessing pain characteristics identifies urgent complications like perforation, guiding whether diagnostic tests or interventions are needed, making pain assessment the initial priority.

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Correct Answer is B

Explanation

Choice A reason: Platelet count assesses bleeding risk but does not measure warfarin’s anticoagulant effect. Warfarin inhibits clotting factors, monitored by INR. Platelet counts are relevant for antiplatelet drugs, not anticoagulants, making INR the priority for evaluating warfarin efficacy in atrial fibrillation.

Choice B reason: INR measures warfarin’s anticoagulant effect by assessing prothrombin time, reflecting vitamin K-dependent clotting factor inhibition. In atrial fibrillation, therapeutic INR (2.0–3.0) prevents thromboembolism. Monitoring INR ensures effective anticoagulation, making it the critical lab value for warfarin therapy management.

Choice C reason: Hemoglobin level detects bleeding, a warfarin side effect, but does not assess its therapeutic effect. INR directly evaluates anticoagulation, ensuring stroke prevention in atrial fibrillation. Hemoglobin is secondary, monitored for complications, not efficacy, making INR the priority lab value.

Choice D reason: Serum potassium is unrelated to warfarin’s anticoagulant action. Electrolyte imbalances may affect cardiac rhythm in atrial fibrillation, but INR measures warfarin’s effect on clotting factors, ensuring therapeutic anticoagulation, making it the essential value to monitor for medication efficacy.

A. Deficiency in antibody production B. Destruction of helper T-cells and CD4 cells C. Proliferation of suppressor T-cells D. Increase in B-lymphocytes

Correct Answer is B

Explanation

Choice A reason: HIV does not primarily cause a deficiency in antibody production. B-cells produce antibodies, but HIV targets CD4 T-cells, impairing their ability to activate B-cells. This indirectly reduces antibody effectiveness, but the primary mechanism is T-cell destruction, not a direct antibody production deficit, making this incorrect.

Choice B reason: HIV infects and destroys helper T-cells (CD4 cells), critical for coordinating immune responses. By reducing CD4 cell counts, HIV impairs activation of B-cells and cytotoxic T-cells, leading to immune suppression. This is the primary mechanism of AIDS-related immune deficiency, making it the correct explanation for HIV pathology.

Choice C reason: Proliferation of suppressor T-cells (regulatory T-cells) is not a primary HIV mechanism. HIV depletes CD4 cells, not suppressor T-cells, which modulate immune responses. While immune dysregulation occurs, the hallmark is CD4 destruction, not suppressor T-cell proliferation, making this an inaccurate description of HIV’s action.

Choice D reason: HIV does not increase B-lymphocyte numbers. It impairs B-cell function indirectly by destroying CD4 cells, which are needed to activate B-cells for antibody production. B-cell hyperactivity may occur in early HIV, but the primary immune suppression results from CD4 cell loss, not B-cell proliferation.

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A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with a history of atrial fibrillation is prescribed warfarin. Which laboratory value should the nurse monitor to assess the medication’s effectiveness?

Correct Answer is B

Explanation

Correct Answer is B

Explanation

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