Exhibits
The nurse is obtaining the client's vital signs prior to an endoscopy.
Complete the following sentence by using the list of options.
The nurse should first anticipate the need to
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"A"}
The nurse should first anticipate the need to Obtain IV access then Prepare to administer IV fluids.
Rationale
First Anticipated Step: Obtain IV Access:
In a client with hypotension and anemia, immediate IV access is crucial to administer fluids or blood
products to stabilize the client’s condition before the endoscopy. Given the client’s low blood pressure and heart rate, they may need IV fluids (such as saline or Ringer's lactate) to help improve circulation and maintain perfusion. This is essential before proceeding with further interventions like the planned endoscopy.
Second Anticipated Step:
Prepare to administer IV fluids:
The client's low blood pressure and the potential for significant blood loss suggest that IV fluids will be necessary to restore blood volume and improve hemodynamic stability before endoscopy. Normal saline or Lactated Ringer's are commonly used for volume resuscitation in this scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The incentive spirometer should be used more frequently (every 1-2 hours) to promote lung expansion and reduce the risk of pneumonia.
B. Bed rest should be minimized to promote circulation and reduce the risk of deep vein thrombosis (DVT).
C. Range-of-motion exercises improve circulation, prevent joint stiffness, and promote overall mobility.
D. Placing a pillow under the knees can interfere with circulation and promote flexion contractures.
Correct Answer is A
Explanation
A. Wearing loose-fitting underwear helps keep the genital area dry and prevents irritation, which can reduce the risk of urinary tract infections (UTIs).
B. The client should void every 2 to 3 hours during the day to help prevent UTIs.
C. The client should drink more fluids, typically 8 glasses (240 mL) or more, to help flush out bacteria from the urinary tract.
D. Bubble baths should be avoided as they can irritate the urinary tract and increase the risk of UTIs.
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