After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

Obtain current vital signs.

Measure abdominal girth.

Observe for flushing

Auscultate breath sounds.

Answer and Explanation

The Correct Answer is A

A.   Vital signs are critical for assessing the client’s current hemodynamic status. Coffee-ground emesis can indicate gastrointestinal bleeding, which might lead to complications like hypovolemia or shock.

Vital signs can provide essential information about the client’s condition and help determine the urgency of intervention. Checking vital signs is a priority in assessing the severity of the situation and guiding further actions.
B.   Measuring abdominal girth is useful in assessing for abdominal distention or fluid accumulation, which can be relevant in some gastrointestinal conditions. However, in the immediate context of coffee- ground emesis, the most urgent concern is evaluating the client's hemodynamic stability rather than focusing on abdominal girth.
C.   Flushing of the skin might be relevant in certain contexts (e.g., reactions to medications or infections), but it is not directly related to the immediate concern of gastrointestinal bleeding and the client’s hemodynamic status. It is less critical compared to assessing vital signs in this situation.
D.   While auscultating breath sounds is important for evaluating respiratory status and detecting any pulmonary complications, it is not the immediate priority in the context of coffee-ground emesis. The primary concern should be assessing for signs of hemodynamic instability that may result from gastrointestinal bleeding.

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Correct Answer is D

Explanation

A. Ensuring that the IV solution is infusing at the prescribed rate is an important task to maintain adequate fluid and electrolyte balance, especially if the client is experiencing signs of shock or low blood pressure. However, this action alone does not address the immediate need to assess or intervene for potential critical issues such as bleeding or severe hemodynamic instability.
B. Listening to lung sounds can help assess for pulmonary complications, such as fluid accumulation or atelectasis, which can be relevant postoperatively. However, in the context of hypotension, tachycardia, and altered mental status, the priority is to address potential critical issues related to circulatory stability and bleeding.
C. It is essential to inform the healthcare provider of the client's condition, but this should be done after initial interventions to stabilize the client. This action is necessary but not the first priority.
D. The first action should be to check for any signs of bleeding, especially after abdominal surgery where internal bleeding is a possibility.

A. Client describes a schedule for antacid use with other prescribed medications. B. Client selects a pattern of small meals alternating with fluid intake. C. Client expresses a willingness to reduce nicotine intake. D. Client agrees to participate in a variety of stress reduction techniques.

Correct Answer is B

Explanation

A. Client describes a schedule for antacid use with other prescribed medications: While antacids might be part of the management plan, they do not address the underlying issue of rapid gastric emptying.
B. This is the most relevant outcome for a client who has developed post-Billroth II dumping syndrome, characterized by nausea, diarrhea, and diaphoresis after meals. Small, frequent meals with fluid intake between meals can help regulate blood sugar levels and reduce the rapid emptying of stomach contents into the small intestine, which is a primary cause of dumping syndrome.
C. Smoking can affect overall health but is not directly related to dumping syndrome.
D. Stress management is important for overall well-being but does not directly address the physiological changes causing dumping syndrome.

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After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses an adult client 24 hours following abdominal surgery and finds the client's blood pressure is 98/40 mm Hg. The client is tachycardiac, restless, and irritable. Which action should the nurse perform first?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?