The nurse initiates a vasopressin drip for the client with gastrointestinal bleeding. What should the nurse consider the priority assessment?

Monitor the electrocardiogram for ST changes.

Monitor for cardiac dysrhythmias.

Monitor for bowel obstruction.

Monitor for hypotension.

Answer and Explanation

The Correct Answer is B

Rationale:

A. ST-segment changes on an ECG indicate myocardial ischemia. While ischemia can occur if vasopressin increases cardiac workload, focusing only on ST changes is too narrow. Continuous monitoring for all types of cardiac dysrhythmias is more comprehensive and critical when using vasopressin.

B. Vasopressin is a potent vasoconstrictor used to control gastrointestinal bleeding, such as bleeding esophageal varices. Its mechanism of action increases systemic vascular resistance and can raise afterload, thereby increasing myocardial oxygen demand. In clients with underlying cardiac disease (common in adults with GI bleeding), this can precipitate dysrhythmias such as ventricular tachycardia, bradycardia, or heart block. Continuous ECG monitoring allows for early detection and immediate intervention if life-threatening arrhythmias occur. This makes cardiac dysrhythmia assessment the priority safety concern while administering vasopressin.

C. Vasopressin does not directly cause bowel obstruction. While general gastrointestinal assessment remains part of comprehensive care, it is not specifically linked to vasopressin therapy or an urgent safety concern.

D. Vasopressin generally increases blood pressure due to vasoconstriction. Hypotension is not an expected effect; in fact, monitoring for hypertension or excessive vasoconstriction might be more relevant. Although blood pressure monitoring is important, it is secondary to cardiac monitoring because dysrhythmias can develop even when blood pressure is stable.

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Correct Answer is B

Explanation

Rationale:

A. Lactulose can cause loose stools, but diarrhea is not the desired therapeutic outcome. Excessive diarrhea can lead to dehydration, electrolyte imbalances, and worsening confusion, which are adverse effects rather than expected responses.

B. Lactulose is used to reduce serum ammonia levels in clients with hepatic encephalopathy by promoting excretion of ammonia through the stool. The expected therapeutic outcome is regular, soft bowel movements, typically two to five per day, without causing excessive diarrhea. This indicates that ammonia is being cleared effectively, reducing neurotoxic effects.

C. Improvement in mental status is the ultimate goal of lactulose therapy, but it may take several doses to achieve. Immediate changes in speech are not expected and do not solely indicate treatment effectiveness.

D. Fetor hepaticus (a characteristic musty breath odor) and asterixis (flapping tremor of the hands) are signs of worsening hepatic encephalopathy. Their appearance would indicate treatment failure or progression of disease, not a positive response.

A. A client with a blood pressure of 170/95 mm Hg B. A client experiencing a "ripping" sensation in the chest. C. A client taking anticoagulants with bloody stool. D. A client with a urine output of 240 mL in 12 hours.

Correct Answer is B

Explanation

Rationale:

A. While this indicates hypertension, it is not immediately life-threatening unless accompanied by other symptoms such as chest pain, shortness of breath, or neurological changes. This client requires assessment and possible intervention but is not the highest priority.

B. A “ripping” or tearing chest pain is highly suggestive of an aortic dissection, a life-threatening emergency. This condition can rapidly lead to aortic rupture, cardiac tamponade, or death. According to the ABC and Maslow priority frameworks, this client requires immediate assessment and intervention, making them the highest priority.

C. This indicates gastrointestinal bleeding, which can be serious, especially in patients on anticoagulants, but the client is likely hemodynamically stable if vital signs are not provided. While urgent, it is not more immediately life-threatening than a suspected aortic dissection.

D. This is oliguria and may indicate early renal compromise, but it is not an immediate threat to life compared to suspected aortic dissection. This client should be assessed promptly but after addressing the highest-risk patientTop of FormBottom of Form

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The nurse initiates a vasopressin drip for the client with gastrointestinal bleeding. What should the nurse consider the priority assessment?

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