A nurse is caring for a patient with acute peritonitis. Which intervention would the nurse expect to see?

Provide small, frequent oral feedings with no concentrated sweets

Insert and maintain a nasogastric tube

Flatten head of bed

Prepare patient for blood transfusion of PRBCs

Answer and Explanation

The Correct Answer is B

Choice A reason: Small, frequent oral feedings are contraindicated in acute peritonitis, as the inflamed peritoneum requires bowel rest to reduce irritation and prevent perforation. Feeding can exacerbate inflammation and bacterial spread, worsening the condition. Patients are typically kept NPO (nothing by mouth) with IV fluids to support recovery.

Choice B reason: Inserting a nasogastric tube is standard in acute peritonitis to decompress the stomach, reducing pressure on the inflamed peritoneum and preventing vomiting. It removes gastric contents, minimizing the risk of further contamination or perforation in the abdominal cavity, supporting healing and reducing complications in this serious condition.

Choice C reason: Flattening the head of the bed is not appropriate for peritonitis. Semi-Fowler’s position (head elevated 30–45 degrees) reduces abdominal pressure and improves respiratory comfort. A flat position may increase intra-abdominal pressure, exacerbating pain and risking complications like perforation, making this an incorrect intervention for peritonitis management.

Choice D reason: Blood transfusion of PRBCs is not routinely indicated for peritonitis unless significant blood loss or anemia is present, which is not typical. Peritonitis management focuses on antibiotics, fluid therapy, and surgical intervention if needed. Transfusions address hemorrhagic complications, not the inflammatory or infectious aspects of peritonitis, making this inappropriate.

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Correct Answer is D

Explanation

Choice A reason: CPTT (likely a typo for aPTT, activated partial thromboplastin time) measures clotting time in the intrinsic pathway, used to monitor heparin therapy. It does not detect protein fragments from fibrinolysis. In DVT, aPTT is normal unless anticoagulation is involved, making it unhelpful for detecting fibrin degradation products.

Choice B reason: INR (international normalized ratio) assesses the extrinsic clotting pathway, primarily for warfarin monitoring. It does not measure fibrin degradation products like D-dimer. In DVT, INR is typically normal unless the patient is on anticoagulants, so it is not useful for confirming fibrinolysis or diagnosing DVT.

Choice C reason: Impedance plethysmography is a non-invasive test measuring blood flow changes in veins, used to detect DVT by identifying obstructions. It does not measure protein fragments or fibrinolysis products. It assesses physical blood flow, not biochemical markers, making it irrelevant for detecting fibrin degradation in DVT.

Choice D reason: D-dimer is a specific test for fibrin degradation products, elevated in DVT due to fibrinolysis of clots. A high D-dimer indicates active clot breakdown, supporting DVT diagnosis. It is sensitive but not specific, requiring imaging confirmation, but it directly addresses the question of detecting protein fragments from fibrinolysis.

A. Administer 25 mL of dextrose 50% IVP B. Encourage the patient to drink orange juice C. Insert a new intravenous access line D. Administer 1 mg of IM glucagon

Correct Answer is C

Explanation

Choice A reason: Administering 25 mL of dextrose 50% IVP would rapidly elevate blood glucose by delivering concentrated glucose, critical for severe hypoglycemia. However, an infiltrated IV line prevents effective delivery, risking extravasation and tissue damage. This action is ineffective without a functional IV, delaying treatment for the patient’s life-threatening low glucose state, which can lead to seizures or coma.

Choice B reason: Encouraging orange juice intake is inappropriate for a patient with altered consciousness, responding only to a sternal rub. Severe hypoglycemia impairs swallowing, increasing aspiration risk. Oral glucose is too slow to correct critical hypoglycemia, requiring immediate parenteral intervention to restore glucose levels and prevent neurological damage or death in this emergency.

Choice C reason: Inserting a new intravenous access line is the priority because the current line is infiltrated, preventing delivery of medications or fluids. A functional IV ensures rapid administration of dextrose to correct severe hypoglycemia. This action addresses the immediate barrier to treatment, enabling life-saving interventions to stabilize the patient’s critically low blood glucose levels effectively.

Choice D reason: Administering 1 mg of IM glucagon stimulates glycogenolysis to release stored glucose, a viable option when IV access is unavailable. However, it is slower than IV dextrose and less effective in patients with depleted glycogen stores, common in severe hypoglycemia. Establishing IV access is prioritized for faster, more reliable glucose delivery in this critical situation.

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A nurse is caring for a patient with acute peritonitis. Which intervention would the nurse expect to see?

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Naxlex Comprehensive Predictor Exams

A patient has symptoms suspicious of deep vein thrombosis. Which lab test would be helpful to see if higher-than-normal amounts of protein fragments secondary to fibrinolysis are present in the blood?

Correct Answer is D

Explanation

A nurse assesses a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning, has a capillary blood glucose of 33 mg/dL (1.8 mmol/L), and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first?

Correct Answer is C

Explanation

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