An adult male client is admitted to the emergency department (ED) while vomiting dark brown, foul smelling emesis. He reports having a surgical repair of a recurrent inguinal hernia a week ago and is troubled by intense abdominal pain. After finding that his bowel sounds are hyperactive, which prescription should the nurse implement first?
Place an indwelling urinary catheter and attach a bedside drainage unit.
Give a prescribed analgesic for temperature above 101° F (38.3° C) orally.
Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS).
Send the client to x-ray for a flat plate of the abdomen.
The Correct Answer is C
Rationale:
A. Place an indwelling urinary catheter and attach a bedside drainage unit: Urinary catheterization may be needed for monitoring output or urinary retention, but it does not address the client’s acute gastrointestinal symptoms.
B. Give a prescribed analgesic for temperature above 101° F (38.3° C) orally: Pain management is important, but giving oral medication is unsafe in a client with persistent vomiting and possible bowel obstruction, as it may not be absorbed and could worsen nausea.
C. Insert a nasogastric tube (NGT) and attach to low intermittent suction (LIS): The client’s symptoms, and recent abdominal surgery suggest a possible postoperative bowel obstruction. Inserting an NGT provides immediate decompression of the stomach, relieves nausea, prevents aspiration, and stabilizes the client before further therapeutic interventions.
D. Send the client to x-ray for a flat plate of the abdomen: Imaging is necessary for diagnosis, but immediate intervention to manage vomiting and prevent complications should take priority over diagnostic testing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["333"]
Explanation
Calculation:
- Total amount of drug and convert to milligrams (mg).
Total drug amount = 1 gram
= 1000 mg.
Total volume of the reconstituted solution = 3.0 mL.
- Calculate the concentration in milligrams per milliliter (mg/mL).
Concentration (mg/mL) = Total drug amount (mg) / Total volume (mL)
= 1000 mg / 3.0 mL
= 333.333... mg/mL.
- Round appropriately to the nearest whole number.
= 333 mg/mL.
Correct Answer is C
Explanation
Rationale:
A. Lethargy: Lethargy is a common symptom of hypothyroidism and, while concerning, is not immediately life-threatening. It requires monitoring but does not necessitate urgent intervention.
B. Cold intolerance: Cold intolerance reflects the decreased metabolic rate in hypothyroidism. It is uncomfortable but not an emergency and can be managed with environmental and clothing adjustments.
C. Hypoventilation: Hypoventilation indicates impaired respiratory function, which can lead to hypoxia and carbon dioxide retention. This is a life-threatening complication requiring immediate intervention to support ventilation and oxygenation.
D. Weight gain: Gradual weight gain is typical in hypothyroidism due to slowed metabolism. While important for long-term management, it does not require immediate action.
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