The nurse is assessing the patient who is

The nurse is assessing the patient who is

• hour post esophagogastroduodenoscopy

(EGD). Which finding should the nurse identify as the highest priority to report to the provider?Temperature of 101.5 F (38.6C).Patient reports a sore throat.Patient’s indwelling catheter has 300mL of clear yellow urine.Patient is currently eating ice chips without difficulty.

• Ask: Highest priority finding to report for patient

• Problem: 1 hour post EGD

• Solution: Findings that could indicate worst potential outcome for the patient

• Correct - temperature may indicate infection and potential perforation
• Incorrect - sore throat is expected
• Incorrect - 300 mL of clear urine is normal
• Incorrect - eating ice chips without difficulty is normal

NCLEX

“BRAIN BUSTER” QUESTION

Answer & Rationale

Which adverse effects should the nurse monitor for in a hospitalized patient with an order for aspirin 325 mg every 6 hours with a diagnosis of cluster headaches? Select all that apply.The presence of dark melana in the stool.Decreased heart rate.Increased ecchymosis noted on the extremities.Increased blood pressure.Tinnitus noted on an exam.

• Ask: Adverse effects of aspirin

• Problem: aspirin (anti-platelet) > easy bleeding, big risk for toxicity

• Solution: adverse effects, things that are side effects, not normal, something that can harm the pt

• Correct - dark stools can indicate bleeding in the GI
• Incorrect - decreased heart rate not an adverse effect of aspirin
• Correct - bruising can indicate bleeding from anti-platelets/decreased clotting
• Incorrect - increased blood pressure is not effect of aspirin
• Correct - tinnitus can indicate toxicity > toxic kidneys and toxic ears

NCLEX

“BRAIN BUSTER” QUESTION

Answer & Rationale

A patient with bleeding esophageal varices has had a Sengstaken-Blakemore tube placed to help prevent and control bleeding. What should the nurse do first if this tube becomes displaced?Auscultate patient’s bowel sounds in all 4 quadrants.Immediately raise the head of bed to at least 30 degrees.Promply trim the tube and deflate the balloon.Quickly call the medical response team.

• Ask: Priority action or what to do first

• Problem: Esophageal varices bleed and tube is coming out

• Solution: Actions to do right now to prevent patient from choking

• Incorrect - listening to bowel sounds does nothing for patient’s airway
• Incorrect - raising head of the bed 30 degrees does nothing for the patient
• Correct - cutting balloon, deflating it keeps airway patent and keeps

patient from choking on the obstruction

• Incorrect - calling for medical response does nothing for the patient right now

NCLEX

“BRAIN BUSTER” QUESTION

Answer & Rationale

A patient is 2 hours status post paracentesis. After the unlicensed assistive personnel(UAP) assisted the patient out of bed, the UAP reports to the nurse, “The patient got dizzy and stumbled while I was helping with transfer to the chair.” What intervention should the nurse perform first?Assess the patient immediately.Call the health care provider immediately.Request assistance from physical therapy.Suggest the UAP monitor vital signs.

• Ask: Priority action of what to do now

• Problem: Dizzy patient who stumbled to the chair per UAP

• Solution: Safety and assessment

• Correct - assess patient to ensure safety
• Incorrect - calling for HCP does nothing for the patient right now
• Incorrect - assistance from the PT does nothing for the patient right now
• Incorrect - UAP to monitor vital signs does nothing to do ensure safety

NCLEX

“BRAIN BUSTER” QUESTION

Answer & Rationale