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After being transferred from the emergency department to a medical unit, a client vomits into an emesis basin. The nurse observes the emesis as seen in the picture. Which assessment should the nurse complete first?
- A. Obtain current vital signs.
- B. Measure abdominal girth.
- C. Observe for flushing
- D. Auscultate breath sounds.
Correct Answer: A
Rationale: Vital signs assess hemodynamic stability, critical for potential gastrointestinal bleeding indicated by coffee-ground emesis, prioritizing over other assessments.
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A client with chronic obstructive pulmonary disease (COPD) has become extremely dyspneic. After determining that the client is in high- Fowler's position and is receiving oxygen via nasal cannula at 2 liters/minute, which immediate action should the nurse take?
- A. Increase the client's oxygen to 6 liters/minute.
- B. Obtain a stat arterial blood gas.
- C. Lower the bed to a semi-Fowler's position.
- D. Encourage the client to use pursed-lip breathing.
Correct Answer: B
Rationale: A stat arterial blood gas evaluates oxygenation and ventilation, guiding treatment for acute dyspnea, prioritizing over oxygen adjustment or positioning.
A client with chronic venous insufficiency is being discharged from the hospital, and plans to return home. Which client statement indicates an understanding of home care instructions?
- A. I will lift weights every other day.'
- B. I will be able to stand as long as my legs do not hurt.'
- C. I will avoid sitting and crossing my legs.'
- D. I will need to get someone to walk my dog.'
Correct Answer: C
Rationale: Avoiding prolonged sitting and leg crossing improves venous return, aligning with chronic venous insufficiency management.
Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Client describes a schedule for antacid use with other prescribed medications.
- B. Client selects a pattern of small meals alternating with fluid intake.
- C. Client expresses a willingness to reduce nicotine intake.
- D. Client agrees to participate in a variety of stress reduction techniques.
Correct Answer: B
Rationale: Small, frequent meals reduce rapid gastric emptying, addressing dumping syndrome symptoms post-Billroth II.
A client with pancreatitis is receiving 0.9% normal saline, and the prescribed IV infusion rate was increased from 100 mL/hour to 150 mL/hour. Which assessment finding indicates to the nurse that the prescription has a therapeutic outcome?
- A. An increase in the hematocrit (HCT) from 42% (0.42 volume fraction) to 52% (0.52 volume fraction).
- B. An increase in the blood glucose level from 130 mg/dl. (7.22 mmol/L).
- C. A decrease in blood urea nitrogen (BUN) from 36 mg/dL (12.9 mmol/L) to 23 mg/dL (8.21 mmol/L).
- D. A decrease in serum amylase from 24 units/dl (240 units) to 12 units/dl. (120 units/L);
Correct Answer: C
Rationale: A decrease in BUN indicates improved renal perfusion, a therapeutic outcome of increased IV fluids. Increased hematocrit suggests fluid volume deficit, increased blood glucose is undesirable, and amylase decrease is not directly related to fluid increase.
A client is admitted to the emergency department 5 days after an acute coronary syndrome (ACS) troubled by severe fatigue, muscle weakness, and shortness of breath. The client's electrocardiogram (ECG) Indicates sinus tachycardia and the laboratory findings indicate an elevated serum brain natriuretic peptide (BNP) level. Which action is most important for the nurse to implement?
- A. Insert an indwelling urinary catheter.
- B. Obtain blood for serum cardiac enzymes.
- C. Provide emotional support.
- D. Auscultate lung fields for fine rales.
Correct Answer: D
Rationale: Auscultating for rales assesses for pulmonary congestion, indicated by elevated BNP and symptoms, prioritizing over catheter insertion or emotional support.