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: Administering insulin as prescribed may be necessary if the client's blood sugar is elevated. However, the priority is to reassess the blood sugar level to confirm the current status before administering insulin.
Choice B rationale: Reassessing the client's blood sugar level is critical to determine if hypoglycemia or hyperglycemia is contributing to the symptoms. Accurate blood sugar measurements guide appropriate interventions and prevent complications.
Choice C rationale: Providing a cool compress for the headache may offer symptomatic relief but does not address the underlying cause of the client's symptoms. The primary concern should be assessing and managing blood glucose levels.
Choice D rationale: Notifying the provider of the client's tremors is important, but the nurse has already notified the provider. Immediate reassessment of blood glucose levels takes precedence to address potential hypoglycemia or hyperglycemia.
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