The correct answer in this question is "Insert two large-bore peripheral IV's."

This is the correct answer because this patient is suffering from a suspected gastrointestinal bleed and based upon the report of the vital signs, he is hemodynamically unstable. In evaluating an emergency/trauma patient, the "ABC's" must be assessed (A= airway, B= breathing, C= circulation). In this patient's case, it is stated that he is responsive and breathing without any issues, indicating that his airway and breathing are both satisfactory. The next issue is his circulation. Given that he has a suspected bleed, and is tachycardic and hypotensive, it is likely that he is losing a significant amount of blood from his bleeding viscera. As such, he may need emergent, rapid fluid and/or blood product resuscitation. The best way to prepare for this immediately is to place two large bore peripheral IV lines, such that resuscitation can be provided through these lines while the rest of the workup and treatment continues. Any delay in placing these lines delays the fluid/blood resuscitation of the patient, which can be dangerous.

At this point, given that the patient has a protected airway and is breathing without issue, intubation would not be indicated. Should his airway or breathing status change, the need can be reassessed.

Administering hydromorphone, a potent opioid, may be necessary if the patient is in a significant amount of pain, but that would not be the most pressing initial concern given that he is hemodynamically unstable.

Administering warfarin, an anticoagulant, would be highly contraindicated in this patient, as he likely has an active gastrointestinal bleed and is hemodynamically unstable.

Administering lorazepam, a benzodiazepine, is not indicated in this hemodynamically unstable patient with a suspected gastrointestinal bleed. After stabilization and continued demonstration of airway protection, if the patient is anxious, this need can be reassessed. 

The correct recommendation is "Eat your last meal at least 3 hours prior to going to bed, and sleep as upright as possible, with multiple pillows." This is correct because this recommendation involves fairly simple lifestyle changes that have the potential to greatly decrease the patient's symptom burden. Heartburn symptoms can be exacerbated in patients who eat spicy foods (at any time), who drink coffee, and/or who eat meals shortly prior to going to bed (since the food can physically reflux back to the distal esophagus from the stomach prior to being digested more completely). Thus, any of those recommendations would be inappropriate. Further, in a patient who is acutely experiencing acid reflux symptoms, it is typically appropriate for them to take calcium carbonate to neutralize the acid and relieve symptoms. As such, advising the patient to not eat immediately prior to going to bed, and to remain upright (to physically minimize reflux of contents) would be the most appropriate recommendation. 

The correct answer is "ondansetron." This is the correct answer because this patient, who is actively being treated with chemotherapy and experiencing severe nausea, is most likely suffering from chemotherapy-induced nausea. The most appropriate first-line treatment for chemotherapy-induced nausea in a patient with a normal QTc interval is ondansetron (also known as Zofran). Ondansetron is a serotonin 5HT-3 receptor antagonist, likely accounting for its anti-nausea properties. A side effect is QTc interval prolongation, and as such, careful consideration as to whether or not to prescribe ondansetron should be given for patients with baseline prolonged QTc intervals. 

Acetaminophen, an analgesic, would not treat nausea, nor would ibuprofen, meloxicam, or ketorolac (all NSAID medications).

The correct answer is "Take 1-2 tablets of calcium carbonate every 3-6 hours as needed for heartburn symptoms, and if you experience symptoms more frequently or severely, return to clinic." This answer is correct because in this patient's case, he is an apparently healthy 40-year old male whose only complaint is very infrequent heartburn that occurs in response to specific trigger foods and drinks (spicy foods and alcoholic beverages). In a patient who experiences mild to moderate heartburn, or acid reflux, symptoms infrequently, meaning less than 3 times per week, the appropriate initial recommendation is to take over-the-counter calcium carbonate tablets as needed, as these will directly neutralize the excess acid in the distal esophagus and stomach. For the majority of patients with infrequent heartburn brought on by known trigger foods and beverages, this will be sufficient to provide symptomatic relief. 

It is inappropriate in a patient with infrequent heartburn who has not yet tried (and failed) calcium carbonate to initiate ranitidine or omeprazole treatment, as these are more potent methods to suppress intrinsic stomach acid production, and are not necessarily required to provide symptomatic relief for these patients. If the patient in this example was experiencing more frequent heartburn, more severe heartburn, or heartburn that was not adequately controlled by calcium carbonate, then ranitidine or omeprazole would be reasonable options. 

The best initial treatment option for a patient with heartburn is not acetaminophen, an over-the-counter analgesic. Heartburn is caused by reflux of acidic gastric contents into the distal esophagus. The best initial treatment for an acute episode of heartburn is calcium carbonate, as this will directly neutralize the acid that is causing symptoms, and provide symptomatic relief for most patients. 

It would be inappropriate to send this patient immediately to the emergency room as he is not currently experiencing heartburn symptoms, his symptoms are highly consistent with heartburn (as opposed to a cardiac etiology), given that they are brought on only infrequently and directly in response to trigger foods and beverages. If the patient was actively complaining of chest pain, and more concerning aspects of his pain were elicited that suggested a cardiac etiology, then an immediate referral to an emergency department would be a more valid consideration.

There are many foods not to be ingested just prior to FOBT, prunes are fine to eat. Red meat, broccoli, cantaloupe, beets, turnips, carrots, horseradish and several others may alter the test results and should be avoided before a FOBT. 

Diverticulitis is the most common cause of lower GI bleeds. Peritonitis and bowel obstruction are possible complications, but not most commonly associated with diverticulitis. Renal failure and severe diarrhea are not complications of diverticulitis.

This patient is experiencing signs of appendicitis, which include periumbilical abdominal pain (usually originating in the right lower quadrant), anorexia, nausea, vomiting, localized tenderness, muscle guarding, and a low-grade fever. Appendicitis is frequently diagnosed in young children and young adults with these symptoms and a white blood cell count from . The nurse should be most concerned if the pain has suddenly ceased, which may be a sign of perforation, which is an emergency due to hemorrhage and infection risks.

Without treatment, appendicitis can lead to peritonitis or perforation. Typical signs and symptoms of appendicitis include periumbilical abdominal pain, anorexia, nausea, vomiting, localized tenderness, muscle guarding, and low-grade fever. The normal WBC count for a patient with appendicitis ranges from . The nurse caring for a patient with appendicitis should always be aware of particularly concerning signs or symptoms of peritonitis, especially those that differ from established baseline signs and symptoms. Many of the symptoms of appendicitis may be apparent with peritonitis, especially tenderness, fever, and white blood cell counts. When assessing for peritonitis, the nurse should specifically look for abdominal rigidity/distention, rebound tenderness, increased/severe abdominal pain, ascites, increased temperature, increased leukocytosis, and paralytic ileus.

Hepatitis B has a long incubation period. From the time of initial infection, symptoms might take from 1-6 months to appear. 

Hepatitis A is a generally benign, self-limiting disease that does not develop into a chronic hepatitis. It also cannot exist in a carrier state. Once the virus is cleared by the immune system, the individual will no longer carry the virus or be infectious to others.