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 {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"F"}

Explanation

Pain relief: One of the primary goals and indications of effective epidural anesthesia is significant reduction or elimination of pain associated with labor contractions, as reflected in the patient asking for and receiving the epidural to manage increasing pain levels.
Progression of labor: Effective epidural anesthesia should allow the labor to progress without adding undue stress or causing significant delays. Monitoring cervical dilation and effacement as well as the baby's descent (station) helps determine if labor is progressing normally even after epidural administration.
Vital signs: Stable vital signs are important indicators that the epidural anesthesia is not causing adverse effects such as severe hypotension or bradycardia, which can sometimes occur with regional anesthesia due to the blockade of sympathetic nerves. Regular monitoring and stability of these signs are crucial for demonstrating effective and safe epidural anesthesia management.

A. Level of consciousness. B. Body mass index. C. Self-description of pain. D. Breath sounds.

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.

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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

Exhibits Drag from the word choices to complete the sentence The client demonstrates effective epidural anesthesia by and ,

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D","dropdown-group-3":"F"}

Explanation

Which information is most important for the nurse to obtain when determining a client's risk for obstructive sleep apnea syndrome (OSAS)?

Correct Answer is B

Explanation

A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

A client is admitted for medical management of a bowel obstruction. The drainage volume from the nasogastric tube over the last 12 hours is 300 milliliters. Which assessment finding provides the earliest indication that the client is experiencing gastrointestinal motility?

When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the client indicates that the teaching was effective?

In evaluating the effectiveness of a postoperative client's intermittent pneumatic compression devices, which assessment is most important for the nurse to complete?

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

The adult child of an older adult client who has Parkinson's disease, calls the clinic and reports that the client has been confused for the past week. What action(s) should the nurse take? Select all that apply.