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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Use nasal or cough tissues followed by handwashing at all times: Hand hygiene and respiratory etiquette are important to reduce infection risk, but they are general preventive measures and not as critical as vaccination for high-risk clients with chronic respiratory diseases.

B. Ensure supplemental oxygen and respiratory medications are available at all times: Having medications and oxygen ready is important for managing acute symptoms, but it does not prevent illness or complications; it is part of ongoing disease management not prevention.

C. Get annual flu and pneumococcal vaccine polyvalent (PPSV23) vaccines: Vaccination is the most important preventive measure for clients with asthma, chronic bronchitis, or emphysema. These clients are at higher risk for respiratory infections, which can cause severe exacerbations, hospitalization, and complications.

D. Avoid large crowded areas during the colder months of the year: Limiting exposure can reduce infection risk but is a situational preventive measure. Vaccination provides broader and more effective protection against common respiratory pathogens.

A. Refrain from sharing towels and razors with others. B. Complete full course of antibiotic therapy. C. Wash hands before and after touching open wounds including bug bites. D. Shower daily with antibacterial soap. E. Eat foods which contain protein and vitamin C

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

• Refrain from sharing towels and razors with others: Prevents transmission of bacteria that can enter through minor skin breaks and cause cellulitis. Maintaining personal hygiene items reduces the risk of reinfection or spreading pathogens to others.

• Complete full course of antibiotic therapy: Promotes healing by ensuring that the bacterial infection is fully eradicated. Stopping antibiotics prematurely can lead to treatment failure, recurrence, or development of resistant organisms.

• Wash hands before and after touching open wounds including bug bites: Prevents future cellulitis by reducing the likelihood of introducing bacteria to compromised skin. Proper hand hygiene is a key preventive measure for both the client and caregivers.

• Shower daily with antibacterial soap: Helps prevent future cellulitis by reducing bacterial load on the skin. Regular cleansing is particularly important in clients with diabetes or peripheral vascular disease, who are more prone to skin infections.

• Eat foods which contain protein and vitamin C: Promotes healing by supporting tissue repair and immune function. Adequate nutrition enhances wound healing, reduces recovery time, and strengthens defenses against infection.

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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

The nurse is reviewing the recommended preventative care for clients with asthma, chronic bronchitis, and emphysema. Which health care measure is most important for the nurse to recommend to these clients?

Correct Answer is C

Explanation

Patient Data Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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