The nurse is obtaining the client's vital signs prior to an endoscopy.
Complete the following sentence by using the list of options.
The nurse should first anticipate the need to
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-1":"B"}
The nurse should first anticipate the need to withhold oral intake then assess the client's vital signs.
Given the client’s symptoms of gnawing abdominal pain, dark tarry stools (indicating possible gastrointestinal bleeding), and pain worsened by eating, withholding oral intake is crucial to prevent further irritation or complications, especially before an endoscopic procedure. This helps avoid complications such as aspiration or exacerbating gastrointestinal issues. After ensuring that oral intake is managed appropriately, the nurse should then assess the client's vital signs to monitor for signs of hemodynamic instability or further deterioration, which can provide critical information about the client's current condition and guide further interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
The client likely suffered from intoxication as evidenced by hypokinesia.
Intoxication from substances such as opioids can lead to a range of symptoms including sedation and altered mental status. In this case, the presence of a needle in the antecubital space and the administration of naloxone suggest opioid use.
Hypokinesia, characterized by reduced movement, aligns with the symptoms observed in opioid intoxication, such as decreased responsiveness and drowsiness. The historical pattern of sedation, miosis (constricted pupils), and mood alteration further supports the diagnosis of intoxication as the underlying condition.
Correct Answer is ["B","E","F","G","H"]
Explanation
A. The oxygen saturation is within normal range hence no need to evaluate further
B. Weight: The client has reported a significant weight loss of 2.26 kg (5 lbs.) over the past week. Unintentional weight loss can be a concerning symptom and may require further assessment.
C. Heart rate: The client's heart rate is within range.
D. Blood pressure is within normal range
E. The temperature is slightly elevated and indicates a need for further evaluation.
F. Sputum characteristics: The client reports "blood-tinged sputum." Coughing up blood in the sputum, known as hemoptysis, is a potentially serious symptom that warrants further evaluation to determine its cause.
G. Respiratory complaint: The client presents with a 4-day history of cough, often productive, along with other respiratory symptoms such as fatigue, night sweats, and a low-grade fever. These respiratory complaints require further evaluation to identify the underlying cause.
H. Travel history: The client recently traveled to South Africa and stayed for 3 weeks.
Travel history is important in assessing potential exposure to infectious diseases or other environmental factors that could contribute to the client's symptoms.
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