A nurse is caring for a 50-year-old male client in the emergency department.
Which finding is most consistent with the client's condition?
Hypoglycemia.
Pancreatitis.
Myocardial infarction.
Gastroenteritis.
The Correct Answer is B
Choice A rationale: Hypoglycemia typically presents with symptoms such as sweating, shakiness, confusion, and palpitations. The client's severe abdominal pain, nausea, vomiting, and jaundice are not consistent with hypoglycemia.
Choice B rationale: Pancreatitis is characterized by severe abdominal pain, nausea, vomiting, fever, and jaundice. The client's symptoms, including severe abdominal pain, nausea, vomiting, and faint yellow hue to sclera, are consistent with pancreatitis2.
Choice C rationale: Myocardial infarction usually presents with chest pain, shortness of breath, sweating, and nausea. The client's primary symptom is severe abdominal pain, which is not typical for myocardial infarction4.
Choice D rationale: Gastroenteritis typically presents with symptoms such as diarrhea, nausea, vomiting, and abdominal cramps. The client's severe abdominal pain, jaundice, and fever are more indicative of pancreatitis than gastroenteritis6.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Sterile water prevents contamination and maintains the client’s safety during administration, reducing the risk of introducing pathogens. It ensures proper medication dissolution for smooth NG tube flow.
Choice B rationale
Mixing medications together increases the risk of drug interactions, altering pharmacokinetics or pharmacodynamics, potentially causing side effects. It is unsafe for administering via an NG tube without compatibility checks.
Choice C rationale
Sublingual medications are designed for absorption through oral mucosa, bypassing first-pass metabolism. Crushing alters this route, reducing effectiveness. They should not be crushed or administered via NG tube.
Choice D rationale
Flushing with only 5 mL of saline is insufficient to clear residue, risking medication clogging. Standard practice suggests using at least 15-30 mL to ensure patency and avoid tube obstruction.
Correct Answer is B
Explanation
Choice A rationale
Monitoring blood pressure trends ensures early detection of medication effectiveness, yet is secondary to addressing critical hypokalemia. Normal blood pressure is 120/80 mmHg; deviations warrant monitoring, but this is not the priority intervention.
Choice B rationale
Administering potassium chloride STAT addresses potential hypokalemia, which risks arrhythmias and muscle weakness. Normal potassium levels range between 3.5-5.0 mEq/L, highlighting urgency when potassium is below normal.
Choice C rationale
Reassessing additional medication needs at a set time ensures comprehensive care but does not address immediate life-threatening conditions like hypokalemia, which requires urgent correction to prevent cardiac dysfunction.
Choice D rationale
Educating about blood pressure maintenance is crucial for long-term management but does not address the immediate physiological imbalance or risk of arrhythmias due to electrolyte disturbance, making it a lower priority.
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