The emergency room nurse is caring for a client just diagnosed with a bowel obstruction secondary to adhesions. Which of the following orders should the nurse complete first?

Hang IV fluids of CSNS with 20 mEq of potassium chloride at 125 ml/hr

Insert a nasogastric tube

Draw a basic metabolic panel

Ambulate in the hallway

Answer and Explanation

The Correct Answer is B

A. Hang IV fluids of CSNS with 20 mEq of potassium chloride at 125 ml/hr: Fluid resuscitation is important, but potassium should not be administered until electrolyte levels are assessed. Also, potassium administration in a client with a bowel obstruction requires caution due to the risk of hyperkalemia if renal function is impaired.

B. Insert a nasogastric tube: A nasogastric (NG) tube is essential in managing bowel obstruction as it helps decompress the stomach, relieve pressure, and prevent aspiration. This should be done first to stabilize the client.

C. Draw a basic metabolic panel: Checking electrolyte imbalances is important but should be done after stabilizing the client with NG tube insertion.

D. Ambulate in the hallway: Ambulation is contraindicated in acute bowel obstruction due to the risk of worsening symptoms such as nausea, vomiting, and severe pain.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The client's ammonia level is critically elevated (250 mcg/dL), which can lead to altered mental status, confusion, and lethargy, consistent with hepatic encephalopathy. In cirrhosis, the liver loses its ability to detoxify ammonia, leading to its accumulation in the bloodstream. This excess ammonia crosses the blood-brain barrier, impairing neuronal function and causing hepatic encephalopathy.

Incorrect answers:

DKA is characterized by high blood glucose (>250 mg/dL), metabolic acidosis, and ketonemia. This client has a moderate glucose elevation (148 mg/dL) but no signs of acidosis, Kussmaul respirations, or ketonuria.

Dehydration: While dehydration can contribute to mental status changes, severe hyperammonemia is a direct cause of hepatic encephalopathy. The client's crackles in the lungs and peripheral edema suggest fluid retention, not dehydration.

Acute kidney disease presents with rising creatinine levels, oliguria, and electrolyte imbalances. This client’s creatinine level is normal, ruling out acute kidney disease.

Malnutrition is characterized by low albumin, muscle wasting, and weight loss, but this client's elevated glucose is more likely due to diabetes mellitus rather than malnutrition.

A. "This condition is correlated to chronic blood loss.” B. "Villi within my intestine are damaged.” C. “Poor nutrition is a causative factor.” D. "The ferrous sulfate is prescribed will replace the lost iron.”

Correct Answer is B

Explanation

A. "This condition is correlated to chronic blood loss.” : Chronic inflammation and ulceration in Crohn’s disease can cause occult GI bleeding, leading to iron-deficiency anemia.

B. "Villi within my intestine are damaged.”: Crohn’s disease affects the entire intestinal wall, but it does not damage villi specifically. Villi damage occurs in celiac disease, not Crohn’s disease.

C. "Poor nutrition is a causative factor.": Malabsorption of iron, vitamin B12, and folate due to inflammation contributes to anemia in Crohn’s disease.

D. "The ferrous sulfate prescribed will replace the lost iron.": Iron supplements (ferrous sulfate) are commonly prescribed for anemia in Crohn’s disease due to chronic blood loss.

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The emergency room nurse is caring for a client just diagnosed with a bowel obstruction secondary to adhesions. Which of the following orders should the nurse complete first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the emergency department (ED). Exhibits Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is exhibiting manifestations of dropdown due to the client’s dropdown.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The nurse is providing education to a client with a history of Crohn's Disease and a new diagnosis of anemia. Which of the following statements by the client would require farther teaching?

Correct Answer is B

Explanation

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