The nurse in the emergency department (ED) has just received a client with bright red emesis and a suspected stomach perforation related to peptic ulcer disease (PUD). What is the priority nursing action?

Document and continue to monitor

Evaluate for tachycardia, hypotension, and tachypnea

Draw a set of serum laboratory tests

Place in a prone position and prepare for surgery

Answer and Explanation

The Correct Answer is B

A. Documentation and monitoring are important but not the immediate priority in an unstable, potentially life-threatening situation.
B. The nurse’s first priority is to assess for signs of hypovolemic shock (tachycardia, hypotension, tachypnea) due to bleeding and perforation. This guides urgent interventions to stabilize the client.
C. Drawing labs is appropriate but not the priority before assessing airway, breathing, and circulation (ABCs).
D. The client should not be placed prone; maintaining supine or semi-Fowler’s positioning is safer while preparing for possible surgery.

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Correct Answer is D

Explanation

A. A Monospot test is used to detect infectious mononucleosis, which is unrelated to chronic ear infections.

B. MRI is generally reserved for evaluating structural abnormalities, tumors, or complications, not routine chronic otitis media.

C. Lumbar puncture is used to diagnose central nervous system infections or conditions like meningitis, not ear infections.

D. Chronic otitis media can lead to hearing loss or speech delays. An audiology consult is appropriate to assess the child’s hearing and determine if further intervention, such as hearing aids or surgical options, is needed.

A. "You need to call the doctor if you have eye discharge in the morning." B. "You need to call the doctor if you get a scratchy feeling in your eye." C. "You need to call the doctor if you get nauseated." D. "You need to call the doctor if you see flashing lights."

Correct Answer is D

Explanation

A. Mild discharge can occur postoperatively and is not unusual.

B. A scratchy feeling is common due to sutures or healing and usually resolves.

C. Nausea may occur from anesthesia or eye drops but is not a direct eye emergency.

D. Flashing lights, floaters, or a curtain-like shadow can indicate retinal detachment, which is a medical emergency that requires immediate intervention to prevent vision loss.

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Heart Rate	115 beats per minute
Blood pressure	100/70 mmHg
Temperature	98.7 F (37.0 C)
Oxygen saturation	90% on room air

Blood Pressure	118/78 mmHg
Heart Rate	112 beats/minute
Respiratory Rate	22 breaths/minute
Temperature	102.8 F (39.3 C)
WBC	16000 (Ret: 4000-11000)
BUN	24 mg/dL (Ref: 8-20 mg/dL)
Creatinine	1.1 mg/dL (Ref: 0.6-1.2 mg/dL)

The nurse in the emergency department (ED) has just received a client with bright red emesis and a suspected stomach perforation related to peptic ulcer disease (PUD). What is the priority nursing action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a child with chronic otitis media infections. Which prescription by the health care provider will the nurse anticipate?

Correct Answer is D

Explanation

The nurse is caring for a client who is ready to be discharged home after a cataract extraction with intraocular lens implant. The nurse is reviewing signs and symptoms that need to be reported to the ophthalmologist immediately. Which symptom is the priority for the nurse to teach the client?

Correct Answer is D

Explanation

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