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Exhibits

Review H and P, nurse's note, laboratory results, and flow sheet.

Complete thee diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

  • Small intestinal obstruction is indicated by the client’s abdominal distension, absence of bowel sounds, refusal to eat, and episodes of vomiting. The laboratory results show metabolic acidosis (HCO3 of 16 mEq), which can be associated with a bowel obstruction.
  • Placing a nasogastric tube helps decompress the stomach and relieve pressure caused by the obstruction, while giving IV fluids helps to prevent dehydration and electrolyte imbalances that can occur with vomiting and obstruction.
  • Monitoring signs and symptoms of dehydration is crucial as the client has been vomiting and may not be able to maintain adequate fluid intake. Monitoring temperature is also essential to detect any signs of infection or complications related to the obstruction.


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Related Questions

Correct Answer is B

Explanation

A. While the nurse can perform oral care, it is essential for the UAP to assist where appropriate, and oral care should not be solely left for the nurse.
B. A soft-bristled toothbrush is the best option for the client with painful mouth ulcers, as it is gentle and reduces the risk of further irritation.
C. Offering mouthwash may not be appropriate, especially if it contains alcohol, as it could further irritate the ulcers; additionally, thorough cleansing is typically more effective with careful brushing rather than rinsing alone.
D. Wearing sterile gloves is unnecessary for oral care; standard precautions, including clean gloves, should be used, but sterile gloves are not required for this type of care.

Correct Answer is D

Explanation

A. While assessing body temperature is important, it is not the most critical action prior to administering vancomycin.
B. Auscultating bowel sounds can provide information about gastrointestinal function but is not specifically required before administering vancomycin.
C. Measuring oxygen saturation is important in assessing respiratory status but is not related to the administration of vancomycin.
D. Checking serum creatinine is essential because vancomycin can affect renal function, and assessing kidney function is critical before administration to prevent potential toxicity, especially in patients with a history of renal impairment.

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