An older adult resident calls the practical nurse (PN) to the room in a long-term care facility. The resident reports an episode of vomiting and shows the PN the contents of the emesis basin. The PN observes the emesis. Which action is most important for the PN to take?
Notify the nursing supervisor of the appearance of the emesis.
Advise the client to report any further vomiting to the PN.
Determine if the client has a PRN prescription for an antiemetic.
Assign an unlicensed assistive personnel to provide mouth care.
The Correct Answer is A
A. Notify the nursing supervisor of the appearance of the emesis:
Coffee-ground emesis indicates upper GI bleeding; requires prompt reporting for evaluation and intervention.
B. Advise the client to report any further vomiting to the PN:
Appropriate for minor issues, but not for potentially serious GI bleed.
C. Determine if the client has a PRN prescription for an antiemetic:
Masking symptoms with antiemetics without addressing cause can delay diagnosis.
D. Assign an unlicensed assistive personnel to provide mouth care:
Comfort measure, but secondary to urgent assessment and provider notification.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Limit play with the stuffed toy when out of tent: Doesn’t address infection control inside tent.
B. Allow the child to have the stuffed toy in the tent: Familiar items reduce anxiety; mist tent moisture doesn’t require toy exclusion if clean.
C. Ask the mother to wash the toy daily: Not necessary unless visibly soiled; overburdens family.
D. Spray toy with disinfectant before placing in tent: Disinfectant residue may be harmful to child.
Correct Answer is A
Explanation
A. Notify the nursing supervisor of the appearance of the emesis:
Coffee-ground emesis indicates upper GI bleeding; requires prompt reporting for evaluation and intervention.
B. Advise the client to report any further vomiting to the PN:
Appropriate for minor issues, but not for potentially serious GI bleed.
C. Determine if the client has a PRN prescription for an antiemetic:
Masking symptoms with antiemetics without addressing cause can delay diagnosis.
D. Assign an unlicensed assistive personnel to provide mouth care:
Comfort measure, but secondary to urgent assessment and provider notification.
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