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":"A"}
Explanation
After notifying the provider about the client's condition, the immediate actions should focus on managing the client's chest pain and potential cardiac event.
Administering oxygen at 2 L/min via nasal cannula helps ensure adequate oxygenation, while administering sublingual nitroglycerin helps alleviate chest pain and improve blood flow to the heart. The incorrect options do not address the immediate needs of a client experiencing chest pain and potential myocardial ischemia.
Correct Answer is B
Explanation
A. Incorrect. No sounds heard after listening for 3 to 5 minutes would be considered absent bowel sounds.
B. Correct. Hyperactive bowel sounds are louder and more frequent than normal and can indicate increased bowel motility. They can also be present in early bowel obstructions due to increased peristalsis.
C. Incorrect. Soft sounds at a rate of 1/min are within the range of normal bowel sounds.
D. Incorrect. Decreased motility would result in hypoactive bowel sounds, not hyperactive.
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