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.
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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Related Questions
Correct Answer is A
Explanation
A. A nasogastric tube prescribed for low intermittent suction is intended to remove gastric contents and prevent accumulation of air and secretions. If the suction is turned off gastric contents can accumulate, risk of vomiting and aspiration increases, especially in a sedated client with a reduced gag reflex, abdominal distention and discomfort may occur, and postoperative complications can develop quickly. Because aspiration directly threatens airway and breathing, this finding requires immediate intervention.
B. A Hemovac drain must be compressed to maintain negative pressure. If not compressed, drainage may not be effective, but this is not immediately life-threatening compared to airway/aspiration risk
C. An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D. Oxygen up to 4 L/min via nasal cannula typically does not require humidification in most clinical settings. May cause mild dryness but is not an immediate threat to airway or life.
Correct Answer is A
Explanation
A. Diarrhea can lead to significant fluid and electrolyte imbalances, especially in older adults. Prioritizing hydration and electrolyte management is essential to prevent severe complications like renal failure or shock.
B. While caregiver stress is significant and must be addressed, it is not as immediately life-threatening as a fluid volume deficit.
C. This is an ongoing management issue but does not pose an immediate threat to the client's life compared to fluid and electrolyte imbalances.
D. Although important for overall care and prevention of complications such as pressure ulcers, it is not as critical as managing fluid volume deficit in this scenario.
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