A client with Crohn's disease is admitted to the medical unit with a three-day history of abdominal cramping, nausea, and vomiting. Which prescription should the nurse implement first?

Send the client to x-ray for a flat plate of the abdomen.

Give a prescribed analgesic for temperature above 101°F (38.3°C).

Place an indwelling urinary catheter and attach to a bedside drainage unit.

Insert a nasogastric tube (NGT) and attach to low intermittent suction.

Answer and Explanation

The Correct Answer is D

Choice A reason: Sending the client to x-ray for a flat plate of the abdomen is important for diagnosing the underlying cause of symptoms, such as bowel obstruction or severe inflammation. However, in the immediate situation, it is essential to relieve the client's symptoms and stabilize their condition first.

Choice B reason: Giving a prescribed analgesic for temperature above 101°F (38.3°C) can help manage fever and pain. However, it is not the first priority. The client’s primary issue is abdominal cramping, nausea, and vomiting, which need to be addressed urgently to prevent further complications.

Choice C reason: Placing an indwelling urinary catheter and attaching it to a bedside drainage unit may be necessary if there are urinary retention concerns. However, this intervention does not directly address the gastrointestinal symptoms that are currently most troubling for the client.

Choice D reason: Inserting a nasogastric tube (NGT) and attaching it to low intermittent suction is the most immediate priority. This action helps to decompress the stomach, relieve nausea and vomiting, and prevent further complications such as aspiration or worsening of the obstruction. It provides immediate symptomatic relief and allows for better management of the client's condition.

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Correct Answer is C

Explanation

Choice A reason: Lung sounds are important to assess for signs of fluid in the lungs, such as crackles, which can occur with fluid volume overload. However, they do not directly measure fluid balance.

Choice B reason: Turgor assesses skin elasticity and hydration status, but it is not the most accurate indicator of overall fluid balance in the context of fluid volume overload.

Choice C reason: Weight is the most accurate and direct measure of fluid balance. Daily weight monitoring can track changes in fluid status, as weight fluctuations can reflect gains or losses in body fluid.

Choice D reason: Blood pressure is important to monitor, especially in clients with fluid volume issues, but it is not the most direct measure of fluid balance. Weight changes provide more precise information about fluid status.

A. Pain in lower legs when walking. B. Black eschar over ankle ulcer. C. Absent pedal pulses by Doppler. D. Dependent rubor of lower extremities.

Correct Answer is C

Explanation

Choice A reason: Pain in the lower legs when walking, also known as intermittent claudication, is a common symptom of PAD but does not indicate an immediate threat to limb viability.

Choice B reason: Black eschar over the ankle ulcer indicates necrotic tissue, which is concerning but not as immediately critical as absent pulses. It does need to be monitored and treated to prevent infection and further complications.

Choice C reason: Absent pedal pulses by Doppler indicate a significant reduction in blood flow to the lower extremities, which can lead to critical limb ischemia and requires immediate intervention to restore perfusion and prevent tissue loss.

Choice D reason: Dependent rubor (redness when the leg is in a dependent position) is a sign of poor arterial circulation but does not require as urgent intervention as absent pedal pulses.

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A client with Crohn's disease is admitted to the medical unit with a three-day history of abdominal cramping, nausea, and vomiting. Which prescription should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

The nurse is assessing a client who was admitted yesterday with peripheral artery disease (PAD) and an ulcer on the lateral malleolus. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

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