The nurse is developing a teaching plan for a client with acute gastritis caused by drinking contaminated water. The nurse should emphasize the need to report the onset of which problem?
Abdominal cramping.
Bruising of the skin.
Low-grade fever.
Bloody emesis.
The Correct Answer is D
Choice A rationale
While abdominal cramping can be a symptom of gastritis, it is not typically a sign of a serious complication that would require immediate medical attention.
Choice B rationale
Bruising of the skin is not typically associated with gastritis. If the client notices unexplained bruising, they should report it, but it is not the most critical symptom to watch for.
Choice C rationale
A low-grade fever can be a symptom of gastritis, but it is not typically a sign of a serious complication. The client should monitor their temperature, but it is not the most critical symptom to watch for.
Choice D rationale
Bloody emesis can be a sign of a serious complication of gastritis, such as a bleeding ulcer. If the client notices bloody or coffee-ground emesis, they should seek medical attention immediately.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Comparing muscle strength bilaterally is not the most important intervention in this situation. While muscle weakness can be a symptom of hyperkalemia, it is not the most immediate concern. Hyperkalemia can lead to life-threatening cardiac dysrhythmias, which is a more immediate threat to the patient’s life.
Choice B rationale
Observing the color and amount of urine can provide information about the patient’s renal function, which is important in the regulation of potassium. However, this is not the most immediate concern when a patient’s serum potassium level is dangerously high.
Choice C rationale
Determining the apical pulse rate and rhythm is the most important intervention. Hyperkalemia can cause cardiac dysrhythmias, so the nurse should immediately assess the patient’s heart rate and rhythm. The nurse should also place the patient on a cardiac monitor, if not already done, and notify the healthcare provider immediately.
Choice D rationale
Assessing the strength of deep tendon reflexes can provide information about neuromuscular function, which can be affected by hyperkalemia. However, this is not the most immediate concern. The nurse’s priority is to assess and monitor for life-threatening cardiac dysrhythmias.
Correct Answer is C
Explanation
Choice A rationale
Activating the synchronization mode is important during cardioversion to avoid delivering a shock during the vulnerable period of cardiac repolarization, which could potentially cause a life-threatening arrhythmia. However, it is not the most crucial action.
Choice B rationale
Choosing a monitor lead with a tall R wave can help ensure that the cardioverter-defibrillator can sense the patient’s intrinsic cardiac activity. However, this is not the most crucial action.
Choice C rationale
Administering the prescribed sedative is the most crucial action before initiating cardioversion. Sedation is necessary to ensure patient comfort and cooperation during the procedure, as cardioversion can be painful.
Choice D rationale
Verifying the prothrombin time (PT) is important in patients receiving anticoagulation therapy, as atrial fibrillation increases the risk of thrombus formation. However, it is not the most crucial action before initiating cardioversion.
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