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. Measure urinary output every hour. Dopamine is commonly used to improve blood pressure and renal perfusion in hypotensive clients. Monitoring urinary output is crucial because dopamine can increase renal blood flow and urine output. Hourly measurement allows for early detection of changes in renal function and urine output, enabling prompt intervention if needed.
B. Initiate seizure precautions. Seizures are not a common adverse effect of dopamine administration. Therefore, initiating seizure precautions is unnecessary in this context.
C. Assess pupillary response to light hourly. While assessing pupillary response is important in neurological assessments, it is not a priority intervention specifically related to dopamine
administration for hypotension.

D. Monitor serum potassium frequently. Dopamine administration is not directly associated with alterations in serum potassium levels. While electrolyte monitoring is important in some
situations, it is not the primary concern when administering dopamine for hypotension. Monitoring urinary output is more pertinent in this scenario.

A. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed. B. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet. C. Estimate the blood pressure by assessing the pulse volume of the client's radial pulses. D. Document why the blood pressure cannot be accurately measured at the present time.

Correct Answer is C

Explanation

A. Demonstrating how to palpate the popliteal pulse is not a suitable alternative for measuring blood pressure when the client cannot be measured in the arms or legs. Palpating peripheral pulses does not provide accurate blood pressure measurements.

B. Advising the UAP to document the last blood pressure obtained is insufficient because it does not address the need for current blood pressure monitoring. Documentation of past
measurements does not provide real-time information about the client's hemodynamic status.

C. Estimating the blood pressure by assessing the pulse volume of the client's radial pulses is a reasonable alternative when traditional blood pressure measurement sites are inaccessible. Although not as accurate as traditional methods, assessing the strength of peripheral pulses can provide valuable information about perfusion and blood pressure status.

D. Documenting why the blood pressure cannot be accurately measured is important for record- keeping but does not address the need for ongoing blood pressure monitoring or provide an alternative method for assessment.

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Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
, dropdown
 and dropdown

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Naxlex Comprehensive Predictor Exams

A client who is hypotensive is receiving dopamine, an adrenergic agonist, intravenously (IV) at the rate of 8 mcg/kg/min. Which intervention should the nurse implement while administering this medication?

Correct Answer is A

Explanation

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is C

Explanation

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?

Exhibits What laboratory specimens would the nurse expect for the provider to order? Select all that apply.

A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?

The nurse is preparing a client with an acoustic neuroma for a magnetic resonance image (MRI). Which client complaint is life-threatening and should be reported to the healthcare provider immediately?

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?