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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Not taking diabetes medication when feeling sick could lead to uncontrolled blood sugar levels.
B. Having rapid-acting glucose readily available indicates understanding of the importance of managing hypoglycemic episodes.
C. While important, obtaining an A1C test annually is not directly related to managing acute hyperglycemia.
D. Using salt, herbs, and spices does not directly address blood glucose control.
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.
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