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. Level of consciousness is not directly related to the risk of OSAS.

B. Body mass index (BMI) is a significant risk factor for OSAS, as higher BMI is strongly associated with increased risk of sleep apnea.

C. Self-description of pain does not relate to the risk factors for OSAS.

D. Breath sounds might be relevant in assessing respiratory status but do not directly indicate the risk for OSAS.

A. Events requiring steroid dose adjustments. B. Need to check temperature daily. C. Importance of recording daily weights. D. Adherence to a high fiber, low fat diet.

Correct Answer is A

Explanation

A. Clients with Addison's disease need to understand situations that require an adjustment in their steroid dose, such as stress, infection, or surgery, to prevent an Addisonian crisis.
B. Daily temperature checks are not typically required for Addison's disease unless there is a concern for infection.
C. While daily weights can be helpful in some conditions, it is not the primary focus for managing Addison's disease.

D. Dietary modifications such as high fiber, low fat may be beneficial for overall health but are not specific to managing Addison's disease.

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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

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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