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

Explanation

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B.Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C.Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D.Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

A. Tell the child he will have to have a shot instead. B. Hide the medication in a large dish of ice cream. C. Tell the child it is candy. D. Offer the child a choice of taking the medication with juice or water.

Correct Answer is D

Explanation

A. Threatening the child with a shot may create anxiety and fear, making cooperation even more challenging.
B. Hiding medication in food without the child's knowledge can lead to mistrust and may not be safe, as the child may not consume the entire dose.
C. Misleading the child about the nature of the medication is not appropriate. It can lead to confusion and mistrust when the child realizes that it is not candy.

D. Providing choices empowers the child and makes the process of taking medication less intimidating. It also helps in engaging the child in their own care, making them feel more in control.

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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

A 2-year-old is brought to the emergency department (ED) with a history of several days of rhinitis and now exhibits a productive barking cough and difficulty breathing. Which additional finding should alert the nurse that the child is experiencing respiratory distress?

Correct Answer is B

Explanation

A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation?

Correct Answer is D

Explanation

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