An elderly male patient, who has been experiencing abdominal pain, is admitted to the hospital from a long-term care facility.
He hasn’t had a bowel movement in 7 days, his abdomen is distended, and he recently vomited 150 mL of dark brown emesis.
In what order should the nurse perform the following interventions? Arrange from highest to lowest priority.
Complete a focused assessment.
Offer PRN pain medication.
Send the emesis sample to the lab.
Elevate the head of the bed.
The Correct Answer is A,D,B,C
- Complete a focused assessment: The first step in managing a patient with abdominal pain and other symptoms is to perform a comprehensive assessment. This will help identify the cause of the symptoms and guide subsequent interventions.
- Offer PRN pain medication: Once the immediate risks have been addressed, managing the patient’s pain is a priority. However, the choice of pain medication will depend on the results of the assessment.
- Send the emesis sample to the lab: Sending the emesis sample to the lab can provide valuable information about the cause of the patient’s symptoms. However, this is not as urgent as the other interventions.
- Elevate the head of the bed: Elevating the head of the bed can help reduce the risk of aspiration, especially in a patient who has vomited. This should be done as soon as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
In a client with gastroenteritis experiencing fever, chills, anorexia, and diarrhea, fluid volume deficit is a major concern. Diarrhea and fever can both lead to significant fluid loss. If not addressed, fluid volume deficit can lead to serious complications such as hypovolemic shock.
Choice B rationale
While impaired bed mobility may be a concern due to the client’s history of stroke, it is not the highest priority in this situation. The immediate physiological needs related to the client’s gastroenteritis and potential fluid volume deficit should be addressed first.
Choice C rationale
Caregiver role strain may be a concern given that the client is dependent on care provided by the spouse. However, this psychosocial issue is not the highest priority when the client is experiencing acute physical symptoms that need immediate attention.
Choice D rationale
Bowel incontinence could be a concern for a client with gastroenteritis. However, the risk of fluid volume deficit due to diarrhea and fever is a more immediate concern.
Correct Answer is A
Explanation
Choice A rationale
The symptoms described - right-sided numbness and weakness in the arm and leg, along with a distinct droop on the right side of the face - are indicative of a stroke. Immediate medical intervention is crucial in such cases. Initiating two large-bore IV catheters would allow for rapid administration of necessary medications and fluids. Reviewing the inclusion criteria for IV fibrinolytic therapy is also important, as this type of therapy can help dissolve the clot causing the stroke and restore blood flow to the brain.
Choice B rationale
While continuous observation for transient episodes of neurological dysfunction is important in the care of a patient with suspected stroke, it is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice C rationale
Elevating the head of the bed to 30 degrees can help reduce intracranial pressure in a patient with a stroke. However, this is not the first course of action. Immediate medical intervention to treat the stroke is the priority.
Choice D rationale
Administering aspirin can help prevent further clot formation and platelet aggregation in patients with certain types of stroke. However, aspirin is not typically the first line treatment in the acute phase of a stroke, especially when the type of stroke (ischemic or hemorrhagic) has not yet been determined.
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