An adult woman who had gastric bypass surgery two weeks ago is admitted because she is exhibiting signs of anastomosis leakage. Her vital signs are: temperature 100°F (37.8°C), blood pressure 98/50 mm Hg, heart rate 135 beats/minute, and respiratory rate 24 breaths/minute. Which intervention is most important for the nurse to include in this client's plan of care?

Replace fluids intravenously based on intake and output.

Record the amount of daily wound drainage.

Assess skin condition and turgor for breakdown.

Turn every 2 hours around the clock from side-to-side.

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is the correct answer because the client's vital signs indicate that she is hypovolemic and dehydrated due to the leakage of gastric contents from the anastomosis site. The nurse should replace fluids intravenously to prevent shock and electrolyte imbalance.

Choice B Reason: Recording the amount of daily wound drainage is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should monitor the wound drainage for signs of infection and report any changes to the physician.

Choice C Reason: Assessing skin condition and turgor for breakdown is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should assess the skin for signs of dehydration and pressure ulcers and provide appropriate skin care.

Choice D Reason: Turning every 2 hours around the clock from side-to-side is important but not the most important intervention for this client because it does not address the immediate problem of fluid loss and hypovolemia. The nurse should turn the client to prevent complications such as pneumonia and atelectasis but also consider the client's comfort and pain level.

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Correct Answer is B

Explanation

Choice A Reason: This is not the first priority because it is not a life-threatening condition. The male adolescent may have gastroenteritis or food poisoning, which can cause dehydration and electrolyte imbalance. The nurse should monitor his vital signs and fluid intake, but he can wait for further assessment.

Choice B Reason: This is the first priority because it is a potential surgical emergency. The female client may have appendicitis, which can cause peritonitis and sepsis if left untreated. The nurse should assess her pain level, vital signs, and abdominal signs, and prepare her for diagnostic tests and possible surgery.

Choice C Reason: This is not the first priority because it is a chronic condition that does not require immediate intervention. The elderly client may have intermittent claudication, which is a symptom of peripheral arterial disease. The nurse should educate him on leg care and exercise, but he can wait for further assessment.

Choice D Reason: This is not the first priority because it is a common condition that can be treated with antibiotics. The child may have a bacterial infection, such as bronchitis or pneumonia, which can cause productive cough and fever. The nurse should auscultate his lungs and check his temperature, but he can wait for further assessment.

A. Increasing confusion of the client. B. Client's healthcare power of attorney. C. Currently prescribed medications. D. Fall at home as reason for admission.

Correct Answer is A

Explanation

Choice A Reason: This is the best action because it describes the current situation of the client and alerts the family to a possible change in the client's status. The nurse should provide the most relevant and urgent information first using the SBAR communication.

Choice B Reason: This is not the first action because it does not address the current situation of the client. The nurse should verify the client's healthcare power of attorney, but this is not a priority at this time.

Choice C Reason: This is not the first action because it does not explain the cause of the client's confusion. The nurse should review the client's medications and assess for any adverse effects, but this is not a priority at this time.

Choice D Reason: This is not the first action because it provides background information that is not directly related to the current situation of the client. The nurse should give a brief history of the client's admission, but this can be done later.

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Naxlex Comprehensive Predictor Exams

When triaging emergency room clients, which client should the nurse assess first?

Correct Answer is B

Explanation

Correct Answer is A

Explanation

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