The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

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ATI RN Custom Exams Set 3 Questions

Question 1 of 5

The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

Correct Answer: D

Rationale: The correct interventions for a client presenting with acute epigastric pain and vomiting bright red blood are to assess the client's vital signs and start an IV with an 18-gauge needle. Assessing vital signs helps in determining the client's current condition and response to treatment, while starting an IV is crucial for administering medications and fluids. Beginning iced saline lavage is not appropriate in this situation as the priority is to stabilize the client and address potential bleeding. Therefore, options A and B are correct choices, making option D the most appropriate answer.

Question 2 of 5

The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. What should the nurse assess when administering magnesium sulfate to the client?

Correct Answer: A

Rationale: The correct answer is A: Deep tendon reflexes. When administering magnesium sulfate to a client with chronic alcoholism, chronic pancreatitis, and hypomagnesemia, the nurse should assess deep tendon reflexes. Magnesium sulfate can depress the central nervous system and decrease deep tendon reflexes, so monitoring them is crucial. Choices B, C, and D are not directly related to the assessment needed when administering magnesium sulfate in this scenario. Arterial blood gases are not typically assessed specifically for magnesium sulfate administration; skin turgor and capillary refill time are more related to hydration status and perfusion, respectively.

Question 3 of 5

The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

Correct Answer: D

Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.

Question 4 of 5

The client has failed to conceive after many attempts over a three-year time period and asks the nurse, "I have tried everything. What should I do now?" Which statement is the nurse's best response?

Correct Answer: A

Rationale: The correct response is to assess the intravenous fluids for rate and volume. In this situation, the client is seeking guidance on fertility issues, not related to intravenous fluids, surgical dressing changes, medication levels, or meal monitoring. The nurse should provide supportive and empathetic guidance, suggesting further options like consulting fertility specialists or exploring additional treatments.

Question 5 of 5

AND Answers

Correct Answer: B

Rationale: When collecting a stool specimen, the nurse should usually take about 1 inch of the specimen or a teaspoonful for testing purposes. This amount is sufficient for laboratory analysis and helps ensure accurate results. It is important for the nurse to follow the proper procedure for specimen collection to maintain accuracy in diagnostic testing.

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