A with acute Gl bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the healthcare provider?

The patient's lungs have crackles audible to the midline.

The patient's BP has increased to 142/94 mm Hg.

The bowel sounds are very hyperactive in all four quadrants.

The NG suction is returning coﬀee-ground material.

Answer and Explanation

The Correct Answer is D

Coﬀee-ground material in the NG suction indicates that there is active bleeding in the upper gastrointestinal tract, which could be a life-threatening situation. This requires immediate medical attention and intervention to control the bleeding and stabilize the patient.

Options A, B, and C are also important assessment data, but they are not as urgent as option D in this scenario.

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Correct Answer is D

Explanation

Although increasing ﬂuid intake and fiber intake are important interventions for preventing constipation, it is important to first assess the patient's current situation and risk factors for constipation. Additionally, while a daily bowel movement is not necessary for everyone, it is important to understand the patient's usual bowel habits and whether or not their current regimen is eﬀective for them. Therefore, the nurse should perform a focused nursing assessment to identify the patient's risk factors for constipation and evaluate their current bowel regimen before providing specific interventions or recommendations.

A. 5.0 mEq/L B. 2.9 mEq/L C. 3.8 mEq/L D. 6.0 mEq/L

Correct Answer is B

Explanation

Furosemide is a loop diuretic that works by blocking the reabsorption of sodium and chloride in the ascending loop of Henle in the kidney, leading to increased urine output. However, this medication can also cause potassium loss through increased urinary excretion, which can lead to hypokalemia (low potassium level). Hypokalemia can cause confusion, weakness, and other neurological symptoms.

The normal range for serum potassium is 3.5 to 5.0 mEq/L. A potassium level of 2.9 mEq/L is below the normal range and is considered hypokalemic. Therefore, the nurse should correlate the client's confusion with the low potassium level and notify the healthcare provider to adjust the medication or provide potassium supplements if indicated.

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A with acute Gl bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the healthcare provider?

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Naxlex Comprehensive Predictor Exams

A 67-year-old patient tells the nurse, “l have problems with constipation now that I am older, so I use a suppository every morning” The most appropriate nursing action at this time is to

Correct Answer is D

Explanation

A client is taking furosemide (Lasix), a diuretic. and becomes confused. Which potassium level does the nurse correlate with this condition?

Correct Answer is B

Explanation

A with acute Gl bleeding is receiving normal saline IV at a rate of 500 ml/hr. Which assessment data obtained by the nurse are most important to communicate immediately to the healthcare provider?

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