Fundamental Case Study
1. Mr. Dunner is admitted to his room accompanied by his wife. Before the nurse can begin the admission assessment, Mr. Dunner states that he needs to “throw up.” The nurse helps him sit up and provides an emesis basin.
Mr. Dunner vomits into the emesis basin and then remains sitting on the side of the bed, stating he may need to “throw up” again.Which assessment should the nurse complete first?
A. Auscultate the bowel sounds.
Another assessment should be completed before assessing the client’s bowel sounds.
B. Palpate for abdominal distention.
Another assessment should be completed before assessing for distention.
C. Correct Observe the color of the emesis.
Since the client is vomiting, the nurse should first observe the color and appearance of the emesis for any obvious bleeding or other indications of risk to the client’s homeostasis.
D. Ask about recent loss of appetite.
This information is not a high priority at this time.
2. Mr. Dunner continues to feel nauseated. Mrs. Dunner remains with her husband while the nurse leaves the room to prepare a PRN dose of a prescribed antiemetic.
Shortly after the nurse administers the antiemetic, Mr. Dunner states he feels “better.” The nurse offers to provide oral care with a mint-flavored foam swab and cool water. Which assessment takes priority while the nurse provides oral care?
A. Assess the sides of the oral cavity for any open sores.
Considering the client’s recent history of nausea and vomiting, another assessment takes priority at this time.
B. Correct Observe for excessive dryness of the mucus membranes.
Because the client has a recent history of nausea, vomiting, and weight loss, the nurse should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness.
C. Palpate the salivary glands for tenderness or swelling.
Considering the client’s recent history of nausea and vomiting, another assessment takes priority at this time.
D.
Mr. Dunner vomits into the emesis basin and then remains sitting on the side of the bed, stating he may need to “throw up” again.Which assessment should the nurse complete first?
A. Auscultate the bowel sounds.
Another assessment should be completed before assessing the client’s bowel sounds.
B. Palpate for abdominal distention.
Another assessment should be completed before assessing for distention.
C. Correct Observe the color of the emesis.
Since the client is vomiting, the nurse should first observe the color and appearance of the emesis for any obvious bleeding or other indications of risk to the client’s homeostasis.
D. Ask about recent loss of appetite.
This information is not a high priority at this time.
2. Mr. Dunner continues to feel nauseated. Mrs. Dunner remains with her husband while the nurse leaves the room to prepare a PRN dose of a prescribed antiemetic.
Shortly after the nurse administers the antiemetic, Mr. Dunner states he feels “better.” The nurse offers to provide oral care with a mint-flavored foam swab and cool water. Which assessment takes priority while the nurse provides oral care?
A. Assess the sides of the oral cavity for any open sores.
Considering the client’s recent history of nausea and vomiting, another assessment takes priority at this time.
B. Correct Observe for excessive dryness of the mucus membranes.
Because the client has a recent history of nausea, vomiting, and weight loss, the nurse should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness.
C. Palpate the salivary glands for tenderness or swelling.
Considering the client’s recent history of nausea and vomiting, another assessment takes priority at this time.
D.