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 B
Explanation
A. Incorrect. When removing tape, it is best to pull in the direction of hair growth to minimize skin trauma.
B. Correct. When performing a wet-to-dry dressing change, the wound should be cleaned from the center to the outer edges to prevent introducing contaminants into the wound.
C. Incorrect. Wet-to-dry dressings are typically used to debride wounds by allowing the moist dressing to dry and adhere to wound debris. Moistening the dressing before removal can disrupt this process.
D. Incorrect. Sterile gloves are not typically necessary for performing a wet-to-dry dressing change, as it is a clean technique.
Correct Answer is B
Explanation
A. Incorrect. Placing the bedside table within easy reach of the bed is important to prevent falls, rather than placing it away from the bed.
B. Correct. Moving the client's bed to the main floor of the house reduces the need to use stairs, which can be a fall risk for clients at risk of falls.
C. Incorrect. Keeping the lighting dim increases the risk of falls. Adequate lighting is important to prevent falls.
D. Incorrect. Area rugs on slick floor surfaces can be hazardous and increase the risk of falls.
They should be removed or secured properly.
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