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 ["0.6"]

Explanation

Calculation:

Convert the client's weight from pounds (lb) to kilograms (kg).

The client's weight is 154 lb.

Client weight (kg) = 154lb/2.2lb/kg

= 70kg.

Calculate the total dose to be administered (units).

The ordered dose is 200 units/kg.

Total dose (units) = 200units/kg×70kg

= 14,000units.

Calculate the volume to administer in milliliters (mL).

Available concentration is 25,000units/mL.

Volume (mL) = Totaldose(units)/Availableconcentration(units/mL)

= 14,000units/25,000units/mL

= 0.56mL.

Round the answer to the nearest tenth.

= 0.6mL.

A. Increase in pulse and fetal rate reactivity. B. Pain in lower quadrant and oliguria. C. Mild discomfort and elevated blood pressure. D. Sharp fundal pain and uterine tenderness.

Correct Answer is D

Explanation

A. Increase in pulse and fetal rate reactivity: While changes in maternal pulse and fetal heart rate can indicate stress or early compromise, these findings alone do not specifically indicate acute maternal hemorrhage or uterine injury that requires immediate intervention.

B. Pain in lower quadrant and oliguria: These signs suggest possible urinary retention or renal compromise but are not the most urgent indicators of acute obstetric bleeding during labor.

C. Mild discomfort and elevated blood pressure: Mild discomfort and hypertension may reflect preeclampsia but do not specifically signal active hemorrhage requiring immediate reporting.

D. Sharp fundal pain and uterine tenderness: These findings are indicative of uterine rupture or abruption, both of which are obstetric emergencies. Profuse vaginal bleeding with uterine tenderness requires immediate notification of the healthcare provider to prevent maternal and fetal morbidity or

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

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Naxlex Comprehensive Predictor Exams

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer is ["0.6"]

Explanation

A client in labor begins bleeding profusely from the vagina. Which findings should the nurse report to the healthcare provider?

Correct Answer is D

Explanation

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