Nokea
The nurse has reviewed the information from the Laboratory Results. The health care provider suspects the client is experiencing upper gastrointestinal bleeding. For each potential prescription, click to specify whether the prescription is anticipated or unanticipated for the care of the client.
- A. Place the client on NPO status
- B. Administer isotonic IV fluid bolus
- C. Administer proton pump inhibitor IV
- D. Collect blood samples for type and crossmatch
- E. Administer heparin for deep venous thrombosis prophylaxis
Correct Answer:
Rationale: Anticipated prescriptions for a client with upper gastrointestinal (GI) bleeding include:
• Placing the client on NPO status to reduce the risk of continued bleeding and vomiting. NPO status is important to
initiate prior to esophagogastroduodenoscopy to reduce aspiration risk.
• Administering an isotonic IV fluid bolus to restore circulating fluid volume and maintain perfusion of vital organs.
• Administering a proton pump inhibitor IV (eg, pantoprazole) to reduce gastric acid secretion and prevent further
irritation and breakdown of suspected peptic ulcers.
• Collecting blood samples for type and crossmatch to ensure blood type compatibility before initiating a blood
transfusion. This client's hemoglobin and hematocrit levels are low, and the client continues to have active bleeding.
Therefore, a blood transfusion should be anticipated to increase blood volume and improve oxygenation and perfusion.
Administering heparin for deep venous thrombosis prophylaxis is not anticipated. Anticoagulation will prolong bleeding
and increase risk for hemorrhagic shock. Anticoagulation is contraindicated for clients with active GI bleeding.
You may also like to solve these questions
I can never get tuberculosis again once I finish treatment
- A. I should take the medications with antacids.
- B. I will notify my health care provider if my urine becomes orange.
- C. I will use additional contraception while taking rifampin
Correct Answer: D
Rationale: Rifampin is often used in the management of both latent and active tuberculosis (TB) but reduces the effectiveness of oral contraceptive
pills. Therefore, the client should be instructed to use additional methods of contraception during treatment and for 1 month following
the completion of treatment (Option 4).
Drag words from the choices below to fill in the blank/blanks. The nurse should immediately follow up on the client's-----------------------and-----------
- A. Weight gain
- B. Blood pressure
- C. Respiratory findings
- D. Lower extremity edema
Correct Answer: C,B
Rationale: Heart failure (HF) is a chronic, progressive condition characterized by impaired ventricular function that leads to decreased cardiac output and
causes blood to back up into the lungs and systemic circulation. This results in fluid volume overload that is commonly treated with diuretics,
such as furosemide (ie, "water pill"), that remove excess fluid through increased urination.
A client with HF who is experiencing dyspnea, inspiratory crackles, weight gain, and peripheral edema is demonstrating fluid volume overload
from a probable acute HF exacerbation. The nurse should immediately follow up on potentially life-threatening findings such as the client's:
• Blood pressure, which is moderately elevated and requires urgent intervention with medications (eg, diuretics). Fluid overload causes
increased pressure in the blood vessels, leading to hypertension that increases afterload. This is especially concerning for HF because
the heart muscle is already weak and cannot withstand additional afterload.
• Respiratory findings (ie, capillary oxygen saturation [SpOz) 90% on room air, inspiratory crackles, tachypnea, dyspnea, labored
respirations) because these likely indicate pulmonary edema. Crackles are a manifestation of pulmonary edema caused by fluid in the
alveoli that leads to impaired gas exchange and hypoxemia.
(Incorrect) Weiaht aain and lower extremity edema are also indicators of fluid volume overload however these findinas are not directly life
Drag words from the choices below to fill in the blank/blanks. The nurse understands that treatment for diabetic ketoacidosis is resolved when the-----------,--------, and ----------
- A. Urine output is >30 mL/hr
- B. Blood glucose is <200 mg/dL (11.1 mmol/L)
- C. Potassium level is >3.5 mEq/L (3.5 mmol/L)
- D. Metabolic acidosis is
resolved - E. Urine specimen is negative
for ketones
Correct Answer: B,D,E
Rationale: Diabetic ketoacidosis (DKA) causes anion gap metabolic acidosis generated by the ketoacid anions and beta-hydroxybutyrate. Anion gap is
calculated based on electrolyte levels to determine the balance of cations and anions (le, acids and bases).
IV insulin infusion may be discontinued on resolution of acidosis and ketosis, which generally occurs with a blood glucose level of <200
mg/dL (11.1 mmol/L). However, measurement of serum glucose alone is inappropriate for monitoring the response to treatment because
ketosis and acidemia may still be present. With fluid resuscitation and correction of hyperosmolality and hyperglycemia, ketoacids disappear
and the anion gap and arterial blood gas results normalize, pointing to resolution of metabolic acidosis and ketonuria ie, ketones in
urine.
Select 5 findings that require immediate follow-up.
- A. left-sided headache
- B. Bilateral lens opacity
- C. 7.9-Ib (3.6-kg) weight loss within the past month.
- D. blurred vision and redness in the left eye
- E. severe pain in the left eye
- F. red conjunctiva.
- G. Left eye: pupil 4 mm and nonreactive to light
Correct Answer: A,D,E,F,G
Rationale: This client is experiencing signs of acute angle-closure glaucoma (ACG), a medical emergency characterized by a sudden elevation in
intraocular pressure (IOP). The onset of symptoms is typically sudden; however, acute ACG requires rapid intervention to prevent permane
vision loss. Manifestations of acute ACG include:
• Blurry vision
• Unilateral headache
• Sudden, severe eye pain
• Conjunctival redness
• Middilated pupils (4-6 mm) nonreactive to light
For each finding below, click to specify if the finding is consistent with the disease process of chronic heart failure or chronic obstructive pulmonary disease. Each finding may support more than one disease process.
- A. Fatigue
- B. Dyspnea
- C. S3 heart tone
- D. Rapid weight gain
- E. Pink, frothy sputum
- F. Barrel-shaped chest
Correct Answer:
Rationale: Chronic heart failure (HF) is a progressive condition characterized by impaired ventricular function that leads to decreased
cardiac output and inadequate tissue perfusion as blood backs up into the lungs and systemic circulation. Common clinical
manifestations of HF include:
• Fatigue and dyspne secondary to impaired gas exchange
• An S3 (eg, ventricular gallop) heart tone, characteristic of HF, occurs during early diastole when blood from the atria
enters the ventricle and hits the less compliant (stiff) ventricular wall, creating an audible vibration
• Rapid weight gain (>5 lb/week [2.3 kg/week]) due to fluid volume overload
• Blood-tinged (ie, pink), frothy sputum due to mixing of blood from the ruptured high-pressured pulmonary veins with
transudative (clear alveolar fluid (pulmonary edema)
Chronic obstructive pulmonary disease (COPD) is a progressive, irreversible respiratory tract condition characterized by
chronic airway inflammation, alveolar destruction and enlargement, and/or increased mucus production. Clients with COPD
have the following:
• Fatigue and dyspnea related to impaired gas exchange
• Appearance of a barrel-shaped chest due to the increased anteroposterior-to-transverse diameter ratio from
hyperinflation of the lungs