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

A haemoglobin of 12 g/dL (7.45 mmol/L) and haematocrit of 42% (0.42 volume fraction).

Vital signs are temperature 99.0°F (37.2°C) orally, heart rate 94 beats/minute, respirations 18 breaths/minute, blood pressure 110/70 mm Hg.

Vomits coffee-grounds emesis.

Reports having sharp epigastric pain.

Answer and Explanation

The Correct Answer is C

Choice A reason: A haemoglobin level of 12 g/dL (7.45 mmol/L) and haematocrit of 42% (0.42 volume fraction) are slightly lower than the reference range but not critically low. This finding is important and needs to be monitored, but it does not require the most immediate intervention.

Choice B reason: The vital signs provided are within normal limits and do not indicate an urgent or life-threatening condition. These should be monitored, but they do not require immediate intervention compared to other findings.

Choice C reason: Vomiting coffee-grounds emesis is a sign of gastrointestinal bleeding, specifically indicating that blood has been in the stomach long enough to be partially digested by stomach acid, giving it a coffee-grounds appearance. This is a serious and potentially life-threatening condition requiring immediate medical intervention to stop the bleeding and prevent further complications.

Choice D reason: Sharp epigastric pain is a common symptom of peptic ulcer disease and indicates inflammation or ulceration. While it is painful and concerning, it does not require the most immediate intervention compared to active gastrointestinal bleeding.

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Correct Answer is A

Explanation

Choice A reason: Administering IV furosemide (a diuretic) is crucial for managing the client's symptoms of fluid overload, as indicated by enema and elevated brain natriuretic peptide (BNP) levels. Furosemide helps reduce the volume of fluid in the body, relieving symptoms of heart failure and improving breathing. It addresses the most urgent need for the client.

Choice B reason: Inserting an indwelling urinary catheter might be necessary for accurate measurement of urine output, especially in a client receiving diuretic therapy. However, it is not the most immediate intervention needed to stabilize the client's condition.

Choice C reason: Monitoring for telemetry ST segment changes is important for clients with cardiac conditions. While it is necessary for ongoing assessment, it does not address the immediate need to relieve fluid overload and improve the client's respiratory status.

Choice D reason: Giving a bronchodilator per inhaler can help with respiratory symptoms related to emphysema. However, in this scenario, the primary issue is fluid overload due to heart failure, which needs to be addressed first with diuretic therapy.

A. Pace the client's care to provide periods of rest. B. Make arrangements for radioactive iodine therapy. C. Administer beta-adrenergic blocking agent. D. Monitor the client's vital signs frequently.

Correct Answer is D

Explanation

Choice A reason: Pacing the client's care to provide periods of rest is important for managing fatigue and preventing overexertion. However, it is not the first action the nurse should take in this situation. Monitoring vital signs is crucial to assess the client's current condition and detect any immediate complications.

Choice B reason: Making arrangements for radioactive iodine therapy is a treatment option for hyperthyroidism. However, this is not the first action the nurse should take. The nurse needs to assess the client's condition and stabilize any immediate issues before considering long-term treatment options.

Choice C reason: Administering a beta-adrenergic blocking agent can help manage symptoms such as a racing heartbeat and nervousness. While this may be part of the treatment plan, it is not the first action the nurse should take. Monitoring vital signs is essential to determine the appropriate interventions.

Choice D reason: Monitoring the client's vital signs frequently is the first action the nurse should take. This helps assess the client's current condition, detect any immediate complications, and guide further interventions. It is crucial to ensure the client's stability before implementing other care measures.

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

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Naxlex Comprehensive Predictor Exams

A client with a history of emphysema and heart failure is admitted to the emergency department with enema, coughing, and shortness of breath. The client's laboratory value for brain natriuretic peptide is elevated. Which prescription is most important for the nurse to implement?

Correct Answer is A

Explanation

The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?

Correct Answer is D

Explanation

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