A male client is admitted to the emergency department while vomiting dark brown, foul- smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?

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

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

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

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

Answer and Explanation

The Correct Answer is C

A.   An indwelling urinary catheter is generally used for monitoring urine output in patients with urinary issues or those who are unable to void. It is not the first-line intervention for a client with symptoms suggesting a possible bowel obstruction or gastrointestinal complication. While monitoring urine output may be important, it does not address the immediate concern of the client’s gastrointestinal symptoms.
B.   An abdominal x-ray can help diagnose conditions such as bowel obstruction, ileus, or other abdominal issues by visualizing the presence of air-fluid levels or distended bowel loops. While this diagnostic step is important, it should follow interventions that might provide immediate symptomatic relief or help manage the suspected condition.
C.   Inserting an NGT and attaching it to low intermittent suction is a critical intervention for managing symptoms of bowel obstruction or severe gastrointestinal distress. The dark brown, foul-smelling vomit and hyperactive bowel sounds suggest that the client might have a bowel obstruction or significant gastrointestinal complication. An NGT can help decompress the stomach, relieve pressure, reduce vomiting, and prevent further gastrointestinal complications.
D.   While providing analgesics for pain and fever is important for overall symptom management, it does not address the immediate cause of the client’s symptoms. The focus should be on diagnosing and managing the underlying issue causing the symptoms, such as a bowel obstruction, rather than just treating pain or fever.

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Correct Answer is D

Explanation

A. Monitoring intake and output can be important for overall fluid management, it is not the most urgent intervention for a client presenting with symptoms suggestive of a stroke or other acute neurological event. The immediate concern should be to evaluate and manage the neurological symptoms rather than focusing on urinary output at this stage.
B. Bilateral intermittent sequential pneumatic compression devices are used to prevent deep vein thrombosis (DVT) in immobile patients. This is not directly relevant to the acute neurological symptoms described and does not address the immediate need for evaluating the cause of the sudden headache and facial droop.
C. While aspirin may be used in some cases to prevent further clot formation in patients with certain types of strokes, administering it without a clear diagnosis and without ruling out contraindications could be harmful. The client needs immediate diagnostic evaluation to determine if a stroke or another condition is present before starting any medication like aspirin.
D. Obtaining a focused history is crucial in the context of sudden onset neurological symptoms. This includes assessing for recent bleeding, trauma, or the use of anticoagulants, which can help in diagnosing and managing conditions like stroke. Understanding the client's medication history and any recent bleeding events is important for guiding appropriate treatment and ensuring safe management.

A. Calcium level 7.2 mg/dL (1.8 mmol/L). B. Potassium level 3.8 mg/dl. (3.8 mmol) C. Sodium level 140 mEq/L (140mmol/L). D. Oxygen saturation level 97%.

Correct Answer is A

Explanation

A. This calcium level is below the normal reference range (8.4 to 10.6 mg/dL or 2.10 to 2.50 mmol/L), indicating hypocalcemia. Calcium plays a crucial role in cardiac muscle contraction and electrical conduction. Low calcium levels can lead to various cardiac dysrhythmias, including prolonged QT intervals and increased risk of ventricular arrhythmias.

B. This potassium level falls within the normal range (3.5 to 5.0 mEq/L or 3.5 to 5.0 mmol/L). Potassium is essential for maintaining normal cardiac rhythm, but a level of 3.8 mg/dL is not abnormal and, therefore, is less likely to be the cause of a dysrhythmia compared to abnormal levels.
C. This sodium level is within the normal reference range (136 to 145 mEq/L or 136 to 145 mmol/L). Sodium levels typically do not directly cause dysrhythmias unless they are extremely high or low, which is not the case here. Thus, a sodium level of 140 mEq/L is not likely to be the primary contributor to the dysrhythmia.
D. This oxygen saturation level is considered normal (95% to 100%). While oxygenation is critical for overall heart function and can influence cardiac health, a saturation level of 97% is not likely to be a direct cause of a dysrhythmia, especially if it falls within the normal range.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Correct Answer is A

Explanation

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