An older adult male reporting abdominal pain is admitted to the hospital from a long-term care facility. It has been 7 days since his last bowel movement, his abdomen is distended, and he just vomited 150 mL of dark brown emesis. In which order should the nurse implement these interventions? (Arrange with the highest priority intervention on top, and lowest priority intervention on bottom.)

Elevate the head of the bed.

Complete focused assessment.

Send emesis sample to the lab.

Offer PRN pain medication

Answer and Explanation

The Correct Answer is A,B,C,D

A.   Elevate the head of the bed. This intervention is the highest priority to prevent aspiration and improve the client's comfort and breathing.
B.   Complete focused assessment. A thorough assessment is necessary to gather more information about the client's condition and guide further interventions.
C.   Send emesis sample to the lab. This helps in diagnosing the underlying cause of the dark brown emesis, which could indicate a serious gastrointestinal issue.
D.   Offer PRN pain medication. Pain management is important but should be done after addressing immediate safety concerns and gathering sufficient assessment data.

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Correct Answer is A

Explanation

A. Test the fluid on the dressing for glucose.
This is the correct action. Clear fluid on a dressing after lumbar spinal surgery could indicate a cerebrospinal fluid (CSF) leak. Testing the fluid for glucose is essential because CSF contains glucose, whereas normal wound drainage does not. A positive glucose test would confirm the presence of CSF, indicating a potential complication that requires immediate medical attention.

B. Mark the drainage area with a pen and continue to monitor.
While monitoring the size of the drainage area can be useful, it is not the immediate priority. The nurse should first determine whether the clear fluid is CSF.

C. Change the dressing using a compression bandage.
Changing the dressing might be necessary, but using a compression bandage without first identifying the nature of the fluid could be inappropriate and potentially harmful if the fluid is CSF.

D. Document the findings in the electronic medical record.
Documentation is important, but it is not the immediate action. The nurse needs to identify the nature of the fluid first.

A. Begin parenteral antibiotic therapy. B. Administer antiemetic agents. C. Provide a high-calorie, high-protein diet. D. Bivalve the cast for distal compromise.

Correct Answer is A

Explanation

A. Begin parenteral antibiotic therapy.
This is the correct answer. Osteomyelitis is a serious bone infection that requires prompt and aggressive antibiotic therapy to prevent further complications and promote healing.

B. Administer antiemetic agents.
Antiemetic agents may be necessary if the client is experiencing nausea or vomiting, but this is not the priority action.

C. Provide a high-calorie, high-protein diet.
While nutritional support is important for healing, initiating antibiotic therapy to address the infection takes precedence.

D. Bivalve the cast for distal compromise.
Bivalving the cast might be necessary if there is evidence of compartment syndrome or impaired circulation, but there is no indication from the question that such a complication is present at this time.

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Naxlex Comprehensive Predictor Exams

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Correct Answer is A

Explanation

An adolescent client with non-union of a comminuted fracture of the tibia is admitted with osteomyelitis. The healthcare provider collects bone aspirate specimens for culture and sensitivity and applies a cast to the adolescent's lower leg. Which action should the nurse implement next?

Correct Answer is A

Explanation

The nurse is providing discharge instructions to a client with gout in the left great toe who received a prescription for prednisone 30 mg by mouth to be administered each day. Which symptom should the nurse explain is most important for the client to report to the healthcare provider?

An adolescent who is brought to the emergency department (ED) with a fever and persistent lower right quadrant abdominal pain is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid-base imbalance?

A client with pancreatic cancer develops ascites, and 2 liters of fluid are removed via paracentesis. Which schedule should the nurse implement to assess the client's blood pressure after this procedure?

Exhibits Which 2 orders should the nurse complete first?

An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm. After confirming the presence of the spasms, which action should the nurse take?

Exhibits To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.

Exhibits The nurse inspects the airway. There is no visible trauma, and the airway appears to be patent. What other assessment items are included in the primary survey? Select all that apply.