After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds.

The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity.

The client with an obstruction of the large intestine who is experiencing abdominal distention.

The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid.

Answer and Explanation

The Correct Answer is B

A. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds: Paralytic ileus is common postoperatively and, while concerning, is usually not immediately life-threatening.

B. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity: Abdominal rigidity suggests possible bowel ischemia or perforation, which are surgical emergencies. This client is at highest risk for rapid deterioration and requires immediate assessment and intervention.

C. The client with an obstruction of the large intestine who is experiencing abdominal distention: While abdominal distention indicates obstruction, it is not immediately life-threatening unless accompanied by signs of ischemia or perforation.

D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid: NG drainage is expected with small bowel obstruction and indicates decompression is occurring. This is less urgent than a client showing signs of peritonitis.

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Correct Answer is ["C","E","G"]

Explanation

A. IV site without redness or swelling: The IV site appears normal with no signs of infiltration or infection, so no immediate follow-up is required. This finding indicates proper IV insertion and maintenance.

B. Temperature: 98.8° F (37.1° C): This is within normal limits and does not indicate fever or infection, so it does not require immediate follow-up.

C. Respirations: 28 breaths/minute: This is above the normal adult range (12–20 breaths/minute) and may indicate respiratory distress due to pain, shallow breathing, or possible pulmonary complications such as atelectasis or pneumonia, requiring close monitoring and follow-up.

D. Heart rate: 92 beats/minute: Slightly elevated but within mild tachycardia range, which could be related to pain or anxiety. It should be monitored but does not require urgent follow-up.

E. Taking shallow breaths: Shallow breathing is concerning in a client with rib fractures, as it increases the risk for hypoventilation, atelectasis, and pneumonia. This requires immediate intervention, such as pain management and respiratory support.

F. Alert and oriented to person, place, time, and situation: Cognitive status is normal, so no follow-up is needed.

G. Pain 8 on a 0 to 10 scale: Severe pain limits deep breathing and mobility, increasing the risk of complications. Pain management should be addressed promptly to improve comfort and respiratory function.

H. Blood pressure: 138/82 mm Hg: Slightly elevated, likely related to pain or stress. Monitor trends, but it does not require immediate follow-up at this time.

A. Engage the client in non-threatening conversations. B. Encourage the client's family to visit more often. C. Encourage the client to participate in group activities. D. Schedule a daily conference with the social worker.

Correct Answer is A

Explanation

A. Engage the client in non-threatening conversations: Establishing a therapeutic nurse–client relationship through simple, supportive communication helps reduce isolation, builds trust, and may encourage the client to begin expressing thoughts and feelings.

B. Encourage the client's family to visit more often: Family involvement can be beneficial, but it may not be effective if the client is withdrawn. Increasing visits without first fostering a supportive environment could overwhelm or further isolate the client.

C. Encourage the client to participate in group activities: Group activities promote social interaction but may feel intimidating or threatening for someone who has been withdrawn for weeks. Gradual re-engagement beginning with one-on-one communication is more appropriate.

D. Schedule a daily conference with the social worker: Involving the social worker can be helpful for comprehensive care planning, but this does not directly address the immediate nursing priority of engaging the client therapeutically and reducing withdrawal.

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After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["C","E","G"]

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