The nurse is caring for a client who has just arrived in the emergency department reporting epigastric pain. The client says that emesis earlier in the day looked like coffee grounds. What does the nurse prepare to do for the client first?
a. Check the client's stool for occult blood.
b. Insert 18-gauge IV lines with normal saline infusions.
c. Insert a nasogastric tube and prepare for gastric lavage.
d. Determine whether the client has a history of ulcers.
B
"Coffee ground" emesis is indicative of bleeding in which the blood has been partially digested by gastric acid. This client is at risk for hemorrhage and severe volume depletion and requires two large-bore IVs immediately. The client next will most likely need a saline lavage. Checking the stool and obtaining a history can be done later when the client is stable.
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Infusing vancomycin through a central venous access would prevent:
a. nephrotoxicity associated with peripheral infusion of vancomycin. b. pain and phlebitis associated with peripheral infusion. c. the need for adult doses to be diluted in a minimum of 200 mL of dextrose or normal saline. d. having to infuse vancomycin for more than 60 minutes.
The nurse is working on establishing a balance strategy training program (BSTP) for patients in a long-term care facility. Which of the following should she expect? (Select all that apply.)
a. The patients will have an increase in func-tional ability. b. The fall rate will decrease. c. The BSTP activities include tossing small bean bags. d. The patients will have weekly sessions to practice activities. e. The activities require a lot of work to in-tegrate into the daily resident program. f. Patients will become more independent.
In order to comply with the U.S. Department of Health and Human Services' most current healthcare goals as stated in Healthy People 2020, the nurse will:
1. Plan a depression screening for senior citizens who regularly have lunch at the senior center. 2. Attend an educational in-service on the use of a new automated blood pressure monitor. 3. Advocate for psychiatric health care for those with no private insurance coverage. 4. Organize a park ‘cleanup day' to assure that the community's children have a safe place to play. 5. Counsel older clients regarding programs available to assist them to live in their homes independently.
The nurse is collecting information from a patient who has history of peptic ulcer disease (PUD). The nurse will evaluate that the goals of therapy for PUD have been met when the patient makes which statements?
1. "I was surprised at how quickly my symptoms went away after I started taking the medications and following the lifestyle changes." 2. "My PUD comes back once in a while if I am under a lot of stress." 3. "My previous doctor said my ulcer was completely healed." 4. "I still have to be very careful about what I eat." 5. "As long as I do not lay down for a couple of hours after I eat, I have no problems."