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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The absence of hair growth on the lower legs is a potential sign of peripheral neuropathy, a common complication of diabetes. Assessing the skin for other signs of neuropathy, such as dryness, cracking, or calluses, would provide further evidence to support this diagnosis.
B. While this might indicate neuropathy, it's not as direct a correlation as the skin appearance.
C. Assessing pulses helps to evaluate peripheral circulation, but it doesn't directly address the issue of hair loss, which is more related to nerve damage.
D. Ecchymosis can indicate a bleeding disorder or trauma, not necessarily neuropathy.

A. What time of day the multivitamin is taken. B. The amount of calcium in the multivitamin. C. Usual activity after taking the multivitamin. D. If the multivitamin is taken with a meal or snack

Correct Answer is B

Explanation

A. While this information might be helpful for general medication management, it is not directly related to the client's risk for osteoporosis.
B. The amount of calcium in the multivitamin is the most crucial follow-up information. For an older adult at risk for osteoporosis, ensuring adequate calcium intake is essential for bone health. Confirming the amount of calcium in the multivitamin helps ensure that the client is receiving enough of this critical nutrient to support bone density and reduce the risk of fractures.
C. This information is not relevant to the client's bone health or risk for osteoporosis.
D. While this information can influence the absorption of certain nutrients, it is not specifically related to calcium absorption or osteoporosis prevention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing a client with type 2 diabetes mellitus (DM), the nurse observes an absence of hair growth on the client's lower legs. Which assessment provides further data to support this finding?

Correct Answer is A

Explanation

An older adult client, at risk for osteoporosis, reports taking a multivitamin daily. In developing a teaching plan for the client, which follow- up Information should the nurse obtain?

Correct Answer is B

Explanation

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

Acute soft tissue injuries provide the nurse with a variety of teaching opportunities. Which instruction should the nurse provide to a client with a soft tissue injury?

Exhibits The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition. For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.

When learning to use an insulin pen, a client with diabetes dials 28 units of regular insulin instead of 24 units, the prescribed dose. Which action should the nurse take?

The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?

The nurse is preparing a teaching plan for a client taking a prescribed diuretic for edema in the lower extremities. Which instruction should the nurse include in this teaching plan?

A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?