A nurse is admitting a client. Review the exhibits to answer the question.
For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated.
Test stools for occult blood
Insert a nasogastric tube, attach to low suction
Administer aspirin for abdominal pain
Initiate IV fluids
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Based on the provided exhibits, here are the considerations for the provider’s prescriptions:
- Test stools for occult blood: Anticipated. Given the client’s report of vomiting brown emesis, which could indicate gastrointestinal bleeding, testing stools for occult blood is a standard diagnostic approach to confirm or rule out bleeding.
- Insert a nasogastric tube, attach to low suction: Anticipated. The client has vomited coffee ground emesis, which is a sign of possible upper gastrointestinal bleeding. A nasogastric tube can help decompress the stomach and remove any remaining blood or gastric contents.
- Administer aspirin for abdominal pain: Contraindicated. Aspirin can exacerbate gastrointestinal bleeding, especially in a client with a history of GERD and current symptoms that may suggest a gastrointestinal bleed.
- Initiate IV fluids: Anticipated. The client’s vital signs indicate tachycardia and hypotension, which, along with the clinical presentation, suggest volume depletion possibly due to vomiting and potential bleeding. IV fluids are necessary to maintain hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Stop the antibiotic infusion immediately and notify the healthcare provider.
- Explanation: This is the correct first action. The client is showing signs of a severe allergic reaction, possibly anaphylaxis. Stopping the antibiotic prevents further exposure to the allergen, and notifying the provider ensures prompt medical intervention.
B. Apply a cool compress to the itchy areas and monitor for further reactions.
- Explanation: While a cool compress may help with itching, it does not address the serious symptoms of anaphylaxis, such as difficulty swallowing and wheezing. Immediate action is required beyond just symptom management.
C. Administer diphenhydramine (Benadryl) as a first-line treatment.
- Explanation: While antihistamines like diphenhydramine are helpful in treating mild allergic reactions, this case suggests anaphylaxis, which requires epinephrine as the first-line treatment. Administering diphenhydramine alone is not sufficient for airway compromise.
D. Assess the client’s throat for swelling and encourage them to drink water.
- Explanation: Assessing for throat swelling is important, but encouraging oral intake is not appropriate when a client has difficulty swallowing, as this could worsen airway obstruction. The priority is stopping the medication and seeking emergency intervention.
Correct Answer is ["A","B","C","G"]
Explanation
Choice A rationale
Contact with infected blood or bodily fluids is a major risk factor for Hepatitis B. The virus is present in the blood and bodily fluids of infected individuals and can be transmitted through direct contact.
Choice B rationale
Unprotected sex is a significant risk factor for Hepatitis B. The virus can be transmitted through sexual contact with an infected person.
Choice C rationale
Sharing dirty needles is a well-known risk factor for Hepatitis B. This is particularly a concern among individuals who inject drugs.
Choice D rationale
Sharing eating utensils is not typically a risk factor for Hepatitis B. The virus is not usually transmitted through casual contact or sharing of utensils.
Choice E rationale
Contact with contaminated food or water is not a risk factor for Hepatitis B. The virus is not transmitted through food or water.
Choice F rationale
Exposure to chemicals or toxins is not a risk factor for Hepatitis B. While certain chemicals and toxins can damage the liver, they do not directly cause Hepatitis B3.
Choice G rationale
Contact with infected feces is not typically a risk factor for Hepatitis B. The virus is primarily transmitted through blood and bodily fluids, not fecal matter.
Choice H rationale
Heavy alcohol consumption is not a direct risk factor for Hepatitis B. However, it can contribute to liver damage and complicate the course of the disease if a person is infected.
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