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A patient with esophageal varices has a Sengstaken-Blakemore tube in place for active bleeding. The provider orders insertion of an additional nasogastric tube. The patient’s family asks, “He already has a tube — why does he need another one?” Which response by the nurse best explains the rationale?  

A nurse is caring for a patient admitted with acute cholecystitis. On the second day of admission, the patient reports their “urine looks like coca cola” and their stool appears “pale.” Laboratory results show a bilirubin of 4.2 mg/dL (reference range 0.3–1.2 mg/dL). Which interpretation by the nurse is most accurate?  

A client is receiving a continuous IV infusion of heparin. The IV pump is currently set to infuse at 18 mL/hr. The available solution is 20,000 units of heparin in 250 mL of D5W. How many units per hour is the client receiving?  Round to the nearest whole number.

A patient newly diagnosed with irritable bowel syndrome tells the nurse, “My doctor keeps asking me about my stress levels. I’m not making this up — my pain and diarrhea are real. Why does stress even matter if this is a bowel problem?” Which response by the nurse best explains the relationship?  

A patient with cirrhosis and portal hypertension has been taking metoprolol for hypertension. His provider discontinues the metoprolol and prescribes propranolol. The patient asks the nurse, “I don’t understand — I was already on a beta blocker. Why do I need a different one?” Which response by the nurse best explains the reason for the medication change?  

A 62-year-old patient with decompensated cirrhosis and severe ascites undergoes a large-volume paracentesis with removal of 6 liters of fluid. Six hours later, the nurse notes: BP: 86/54 mmHg HR: 118 bpm Urine output: 15 mL/hr Serum creatinine: increased from 1.0 to 1.9 mg/dL Sodium: 126 mEq/L Abdomen: softer, less distended No evidence of bleeding Which interpretation by the nurse is most accurate?  

A patient with chronic alcohol use disorder is admitted and placed on a protocol including diazepam to prevent alcohol withdrawal syndrome. His last drink was 12 hours ago.  The nurse understands that this medication is effective because it:    

A 48-year-old woman is admitted with severe acute pancreatitis. Vital signs at 0700 are: BP 88/54 mmHg, HR 118 bpm, RR 28/min, O₂ saturation 89% on room air, temperature 38.2°C. She reports abdominal pain and has vomited twice overnight. Laboratory results show: Na⁺ 132 mEq/L, K⁺ 3.1 mEq/L, amylase 420 U/L (normal 30–110 U/L), lipase 550 U/L (normal 23–300 U/L). Which patient outcome should the nurse prioritize?  

Q45. The nurse is administering filgrastim to a patient who is post-bowel resection related to cancer. The patient asks the reason for the medication. What will the nurse explain as the purpose of the medication?

A 54-year-old male with a history of cirrhosis and esophageal varices is brought to the emergency department after vomiting large amounts of bright red blood. He continues to retch violently and has blood trickling from the corners of his mouth. On assessment, the patient is pale, diaphoretic, and anxious. Vital signs: BP 88/54 mmHg, HR 128 bpm, RR 28/min, SpO₂ 91% on room air. Which nursing action takes the highest priority at this moment?