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. Instructing the client's family about the purpose of mitten restraints requires nursing judgment and explanation. It is beyond the scope of an assistive personnel's role.
B. Correct. Assisting the client with a range of motion exercises of the hands is a task that can be safely delegated to assistive personnel. It is a routine activity and does not require advanced assessment.
C. Incorrect. Evaluating the need for the client to remain in restraints requires nursing assessment and decision-making.
D. Incorrect. Determining the circulation status of the extremities requires nursing assessment skills and clinical judgment. It is not appropriate to delegate this task to assistive personnel.
Correct Answer is D
Explanation
Stevens-Johnson syndrome (SJS) is a severe and potentially life-threatening skin reaction that can occur as a rare but serious side effect of allopurinol. The initial symptom often presents as a skin rash, which can progress rapidly and involve other mucous membranes such as the mouth and eyes. Fever is commonly associated with SJS.
Diplopia (double vision) is not a typical symptom of SJS. It refers to seeing two images instead of one and can be caused by various factors unrelated to allopurinol or SJS.
Tinnitus with ear pain is not a characteristic symptom of SJS. It usually relates to issues with the auditory system, such as damage to the inner ear or other underlying conditions.
Hyperreflexia (exaggerated reflexes) is not directly associated with SJS. It typically refers to an abnormal increase in the body's reflex responses and can be caused by conditions affecting the central nervous system or spinal cord.
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