Nokea
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
- A. Document the output and vital signs
- B. Draw blood for hemoglobin and hematocrit
- C. Lower the head of the bed
- D. Notify the registered nurse
Correct Answer: C
Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.
You may also like to solve these questions
Which of the following instructions should be given to a client regarding testicular self-exam?
- A. The testicular exam should be done bimonthly.
- B. The testicular exam should be done while in the shower or tub.
- C. A small pen light should be used to transilluminate the scrotal sac.
- D. The testicular exam should be done yearly.
Correct Answer: B
Rationale: Testicular self-examination (TSE) is recommended monthly, not bimonthly or yearly, and is best performed during or after a warm shower or bath when the scrotum is relaxed, making it easier to detect abnormalities. Transillumination is a medical procedure, not part of TSE.
The nurse is preparing to administer phenytoin oral suspension via nasogastric tube to a client with a seizure disorder. The client is receiving continuous enteral feedings. Which of the following actions should the nurse take?
- A. Obtain the client's blood pressure.
- B. Check the client's pancreatic enzyme levels.
- C. Verify placement of the tube after administering the medication.
- D. Holdphysics://www.youtube.com/watch?v=9Q7sE1Xh_1QHold the enteral feeding for 1 hour before administering the medication.
Correct Answer: D
Rationale: Phenytoin binds to enteral feedings, reducing absorption. Holding feedings for 1 hour before and after administration ensures efficacy. Tube placement should be verified before, not after, administration. Blood pressure and pancreatic enzymes are unrelated.
A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse anticipate in this client's care plan?
- A. Encourage client to drink cold beverages
- B. Encourage client to eat a high-fiber diet
- C. Encourage client to perform facial massage
- D. Encourage client to report any fever or sore throat
Correct Answer: D
Rationale: Carbamazepine can cause agranulocytosis or infections; fever or sore throat must be reported. Cold beverages may trigger trigeminal neuralgia pain. High-fiber diets and facial massage are unrelated to management.
The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti and meatballs
Correct Answer: C
Rationale: Turkey contains the least amount of fat and cholesterol. Cheese, shrimp, and beef should be avoided by the client on a low cholesterol, low fat diet; therefore, answers A, B, and D are incorrect.
A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
- A. Ask the client if he has noticed any bleeding or dark stools
- B. Tell the client to call 911 and go to the emergency department immediately
- C. Schedule a repeat Hemoglobin and Hematocrit in 1 month
- D. Tell the client to schedule an appointment with a hematologist
Correct Answer: A
Rationale: Ask the client if he has noticed any bleeding or dark stools. These values indicate mild anemia, and the first step is to assess for potential sources of blood loss.