Nokea
After receiving change-of-shift report, which of the following patients should the nurse assess first?
- A. A patient who was admitted yesterday with gastrointestinal (GI) bleeding and has melena
- B. A patient who is crying after receiving a diagnosis of esophageal cancer
- C. A patient with esophageal varices who has a blood pressure of 90/54 mm Hg
- D. A patient with nausea who has a dose of metoclopramide (Reglan) scheduled
Correct Answer: C
Rationale: The patient's history and blood pressure indicate possible hemodynamic instability caused by GI bleeding. The data about the other patients do not indicate acutely life-threatening complications.
You may also like to solve these questions
The nurse is teaching a patient with gastroesophageal reflux disease (GERD) about the medication omeprazole. Which of the following information should the nurse include when teaching the patient about this medication?
- A. It neutralizes stomach acid and provides relief of symptoms in a few minutes.
- B. It reduces the reflux of gastric acid by increasing motility.
- C. It coats and protects the lining of the stomach and esophagus from gastric acid.
- D. It treats gastroesophageal reflux disease by decreasing stomach acid production.
Correct Answer: D
Rationale: Omeprazole is a proton pump inhibitor that decreases the rate of gastric acid secretion. Promotility drugs such as metoclopramide increase the rate of gastric emptying. Cytoprotective medications such as sucralfate protect the stomach. Antacids neutralize stomach acid and work rapidly.
Which of the following assessment findings in a patient who had a total gastrectomy 12 hours previously is most important to report to the health care provider?
- A. Absent bowel sounds
- B. Scant nasogastric (NG) tube drainage
- C. Complaints of incisional pain
- D. Temperature 38.9°C (102°F)
Correct Answer: D
Rationale: An elevation in temperature may indicate leakage at the anastomosis, which may require return to surgery or keeping the patient NPO. The other findings are expected in the immediate postoperative period for patients who have this surgery.
The nurse is assessing the mouth of a patient who uses smokeless tobacco for signs of oral cancer. Which of the following findings is of most concern?
- A. Bleeding during tooth brushing
- B. Painful blisters at the border of the lips
- C. Red, velvety patches on the buccal mucosa
- D. White, curdlike plaques on the posterior tongue
Correct Answer: C
Rationale: A red, velvety patch suggests erythroplasia, which has a high incidence (90%) of progression to malignant cancer. The other lesions are suggestive of acute processes (gingivitis, oral candidiasis, and herpes simplex).
The nurse is caring for a patient with deep partial-thickness burns who is anxious about the upcoming dressing change, is in severe pain, and is nauseated. Which of the following actions will be most useful in decreasing the patient's nausea?
- A. Keep the patient NPO for 2 hours before and after dressing changes.
- B. Avoid performing dressing changes close to the patient's mealtimes.
- C. Administer the prescribed morphine sulphate before dressing changes.
- D. Give the ordered prochlorperazine before dressing changes.
Correct Answer: C
Rationale: The patient's nausea is associated with stress and severe pain, therefore the best treatment will be to provide adequate pain medication before dressing changes. The nurse should avoid doing painful procedures close to mealtimes, but nausea or vomiting that occurs at other times also should be addressed. Keeping the patient NPO does not address the reason for the nausea and vomiting and will have an adverse effect on the patient's nutrition. Administration of antiemetics is not the best choice for a patient with nausea caused by pain.
The nurse is caring for a patient who has been NPO during treatment for nausea and vomiting caused by gastric irritation and is to start oral intake. Which of the following menu choices should the nurse offer to the patient?
- A. A glass of orange juice
- B. A dish of lemon gelatin
- C. A cup of coffee with cream
- D. A bowl of hot chicken broth
Correct Answer: B
Rationale: Clear liquids are usually the first foods started after a patient has been nauseated. Acidic foods such as orange juice, very hot foods, and coffee are poorly tolerated when patients have been nauseated.