A client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for an oral temperature of 103°F (39.4°C) and an IV infusion of normal saline is initiated at 250 ml/hour. Which assessment finding should the nurse report to the healthcare provider immediately?

Petechial haemorrhage under client's eyes.

Right lower abdomen rebound tenderness.

Severe headache with photosensitivity.

Dark green coloured emesis.

Answer and Explanation

The Correct Answer is B

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

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Correct Answer is C

Explanation

Choice A reason: Cold intolerance is a common symptom of hypothyroidism due to the reduced metabolic rate. While it is important to address this symptom, it does not require immediate intervention compared to respiratory issues.

Choice B reason: Weight gain is also a common symptom of hypothyroidism because of the decreased metabolism. It is significant but not immediately life-threatening, so it does not take priority over more urgent conditions.

Choice C reason: Hypoventilation is the most critical finding because it indicates respiratory depression. This can lead to severe hypoxia and carbon dioxide retention, potentially causing life-threatening complications. Immediate intervention is required to support the client's breathing and prevent respiratory failure.

Choice D reason: Lethargy is a common symptom of hypothyroidism due to the overall slowing of the body's functions. While concerning, it is not as immediately dangerous as hypoventilation, which directly affects the client's ability to breathe effectively.

A. Continue the normal saline IV at 75 mL/hour and encourage increased oral fluid intake. B. Slow the normal saline to a keep open rate while contacting the healthcare provider. C. Review the client's medications to see if the client can be given a PRN diuretic. D. Instruct the client to withhold oral fluids and report the symptoms to the provider.

Correct Answer is A

Explanation

Choice A reason: Continuing the normal saline IV at 75 mL/hour and encouraging increased oral fluid intake is the appropriate action. The client is showing signs of dehydration, such as dry mucous membranes and inelastic skin turgor, indicating a need for more fluids. Ensuring proper hydration through both IV and oral routes is essential.

Choice B reason: Slowing the normal saline to a keep open rate while contacting the healthcare provider is not appropriate in this situation. The client needs more fluids, not less. Reducing the IV rate could exacerbate dehydration.

Choice C reason: Reviewing the client's medications to see if the client can be given a PRN diuretic is not suitable for a client showing signs of dehydration. Diuretics would further decrease fluid volume and worsen the symptoms.

Choice D reason: Instructing the client to withhold oral fluids and report the symptoms to the provider is contrary to managing dehydration. The client needs increased fluid intake to address the signs of dehydration effectively.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is newly diagnosed with hypothyroidism. Which assessment finding requires immediate intervention?

Correct Answer is C

Explanation

A client who is receiving normal saline IV at 75 mL/hour has dry, sticky mucous membranes, and inelastic skin turgor. Which action should the nurse implement?

Correct Answer is A

Explanation

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide the client?

A client with newly diagnosed Crohn's disease asks the nurse about dietary restrictions. How should the nurse respond?

A client with fluid volume overload is admitted to the hospital for diuresis. Which assessment should the nurse perform to evaluate the client's fluid balance?

The home health nurse visits a client who has a serum sodium level of 123 me/L (123 mmol/L). To explore possible etiologist for this value, what question should the nurse ask the client?

When teaching a client with Parkinson's disease, which rationale for the prescription of carbidopa-levodopa should the nurse include?

A client with peptic ulcer disease (PUD) is admitted to the medical unit. Which assessment finding requires the most immediate intervention by the nurse?