An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Palpate all peripheral pulses in the extremities.

Encourage cough and deep breathing exercises.

Complete a focused assessment of the abdomen.

Initiate measurement of fluid intake and output.

Answer and Explanation

The Correct Answer is C

A.   While assessing peripheral pulses is important, it's not the priority in this situation. The primary concern is the rectal bleeding.
B.   These exercises are important to prevent postoperative complications like pneumonia, but they are not the immediate priority when a patient is experiencing rectal bleeding.
C.   Assessing the abdomen will help determine the severity of the bleeding, identify any signs of abdominal distention or tenderness, and provide crucial information for further interventions.
D.   Monitoring fluid intake and output is important for any patient, but it's not the initial priority when a patient is actively bleeding.

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Correct Answer is B

Explanation

A. While oxygen saturation is important, it's not the priority in this situation. The client's symptoms strongly suggest hypoglycemia.
B. The client's symptoms of diaphoresis, rapid heartbeat, and shakiness are classic signs of hypoglycemia. Therefore, the first action should be to confirm this diagnosis by checking the blood glucose level.
C. Administering glucose before confirming hypoglycemia can be dangerous. If the client is hyperglycemic, giving them sugar will worsen their condition.
D. Providing food without confirming hypoglycemia is not appropriate.

A. Anxiety B. Hyperglycemia C. Fever D. Dyspnea.

Correct Answer is D

Explanation

A. Anxiety is a common symptom in patients with thyrotoxicosis due to increased metabolic activity and overstimulation of the nervous system. While anxiety can be distressing, it is not typically life- threatening and does not usually require immediate intervention.
B. Hyperglycemia (high blood glucose levels) can occur in patients with thyrotoxicosis due to increased metabolic rate and potential effects on insulin sensitivity. It requires monitoring and management but typically does not demand immediate intervention unless it is severe and causing other complications.
C. Fever can be a sign of thyroid storm, a severe form of thyrotoxicosis that can be life-threatening. Elevated body temperature in the context of thyrotoxicosis requires prompt assessment as it may indicate an underlying severe condition or complications.
D. Dyspnea is a critical symptom that warrants immediate intervention. In the context of thyrotoxicosis, it may indicate a severe complication such as heart failure, thyroid storm, or respiratory distress. Given that dyspnea can lead to compromised oxygenation and potentially life-threatening situations, it is the most urgent symptom to address.

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An adult client is admitted to the medical unit due to rectal bleeding after a colonoscopy in which a polyp was biopsied and cauterized. Which Intervention should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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