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

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

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

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

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

Answer and Explanation

The Correct Answer is A

A.   Abdominal rigidity in a client with a bowel obstruction due to a volvulus indicates possible peritonitis, which is a medical emergency.
B.   Paralytic ileus with absent bowel sounds is concerning but not immediately life- threatening.
C.   A nasogastric tube draining greenish fluid is expected in small bowel obstruction.

D. Abdominal distention in large intestine obstruction is concerning but less urgent than potential peritonitis.

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Correct Answer is ["B","H"]

Explanation

A. Not a priority compared to monitoring vital signs and ensuring adequate oxygenation.

B: Increased oxygen flow is necessary to manage the client's respiratory distress and history of smoking. Correct Answer: 3 L, not 1 L as initially listed.
C: Acetaminophen 350 mg PO q4h for temperature greater than 101 F (38.3°C): Important for fever management but not the first priority in acute respiratory distress.
D: Helps maintain hydration but is secondary to respiratory support in this scenario.

E: Not applicable as there is no immediate need for surgery or risk of aspiration currently indicated.
F: Important for medication administration and fluid balance but follows after ensuring respiratory function.
G: Useful for diagnosing the cause of respiratory symptoms but not a first-line action.

H: Essential for continuously assessing the client's respiratory and cardiac status due to difficulty breathing.

A. Case Manager B. Occupational Therapist C. Speech Therapist D. Respiratory Therapist E. Chief Nursing Officer F. Medical Assistant G. Pharmacy Technician H. Physical Therapist

Correct Answer is ["A","B","C","H"]

Explanation

A. A case manager can coordinate the overall care plan, ensuring the client receives appropriate services and support during recovery and discharge planning.
B. An occupational therapist can help the client regain the ability to perform activities of daily living (ADLs) and improve fine motor skills affected by the stroke.
C. A speech therapist can assist the client with speech and language difficulties, as well as swallowing issues that may have resulted from the stroke.
D. A respiratory therapist is typically involved if there are respiratory issues, which are not indicated in this case.
E. A chief nursing officer provides leadership and oversight roles, and not direct patient care.
F. A medical assistant is typically involved in basic clinical tasks but not in specialized stroke recovery.
G. A pharmacy technician fills prescriptions but doesn’t directly participate in client rehabilitation.
H. A physical therapist can help the client improve strength, balance, and mobility, which are often impaired after a

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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

What 2 orders should the nurse complete first?

Correct Answer is ["B","H"]

Explanation

Correct Answer is ["A","B","C","H"]

Explanation

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