The nurse is assessing a client with peptic ulcer disease (PUD). Which finding, if observed by the nurse, would require immediate follow-up?
Low urine output.
Vomiting after a meal.
Blood in the stool.
Abdominal discomfort.
The Correct Answer is C
Choice A rationale
Low urine output could be due to dehydration, medication effects, or stress. While it warrants further assessment, it is not typically associated with immediate life-threatening complications in the context of PUD.
Choice B rationale
Vomiting after a meal can occur in PUD due to delayed gastric emptying or irritation. However, it does not immediately indicate a complication requiring urgent follow-up unless accompanied by other symptoms such as severe pain or hematemesis.
Choice C rationale
Blood in the stool may indicate gastrointestinal bleeding, a serious complication of PUD. This finding requires immediate evaluation to determine the source and extent of bleeding, as it can lead to hypovolemic shock if untreated.
Choice D rationale
Abdominal discomfort is common in PUD due to gastric irritation or acid-related issues. While it requires management, it does not typically signal an urgent complication unless associated with other alarming symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Checking blood pressure does not directly address the faint pulses and cool foot. While hypotension could contribute to peripheral perfusion issues, the signs described more likely indicate compartment syndrome, which requires urgent action.
Choice B rationale
Repositioning the leg might provide some comfort but does not alleviate the potential compartment syndrome. Elevation could worsen ischemia by reducing arterial blood flow.
Choice C rationale
Compartment syndrome is a medical emergency caused by increased pressure within a muscle compartment. This pressure compromises circulation and tissue viability. The nurse must notify the health care provider immediately to prevent permanent damage.
Choice D rationale
Assessing the incision for redness delays addressing the critical signs of potential compartment syndrome. Redness indicates infection, but faint pulses and a cool extremity necessitate more urgent evaluation.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
Blood pressure of 85/55 indicates hypotension, which can compromise perfusion to vital organs such as the brain and kidneys. Immediate assessment is necessary to determine the underlying cause, such as dehydration or internal bleeding.
Choice B rationale
Hemoglobin level of 7 g/dL is critically low, falling below the normal range of 12–16 g/dL for women or 13–18 g/dL for men. This reflects severe anemia, which may require urgent intervention, including blood transfusion or addressing the cause of anemia.
Choice C rationale
Massive bleeding from the right lower leg is an emergency due to the risk of hypovolemic shock and significant blood loss. Stabilization of the bleeding site and monitoring for signs of systemic impact is required immediately.
Choice D rationale
A temperature of 96.5°F (35.8°C) may signal mild hypothermia or a systemic condition. While it requires follow-up, it is not as immediately life-threatening as the other findings and therefore does not warrant immediate prioritization.
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