Exhibits

A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?

Initiate an IV access for the client.

Administer pain medication to the client.

Send the client to radiology for a CT scan.

Insert an NG tube for the client.

Answer and Explanation

The Correct Answer is A

A.   Initiating IV access is a priority to establish a route for medication administration and fluid resuscitation, which are crucial in the management of acute pancreatitis.
B.   Administering pain medication is important, but establishing IV access should be prioritized to ensure timely delivery of medications and fluids.
C.   Sending the client to radiology for a CT scan may be necessary but should not take precedence over establishing IV access for immediate intervention.
D.   Inserting an NG tube may be indicated later in the client's care but is not the first priority compared to establishing IV access.

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Correct Answer is D

Explanation

A. A wall suction setting of 60 mm Hg is within the expected range for low intermittent suction. This indicates the NG tube is likely functioning appropriately in terms of suction pressure.

B. Greenish-yellow drainage is an expected finding and reflects bile-stained gastric contents. This suggests the NG tube is effectively removing gastric secretions.

C. An aspirate pH of 3 is acidic and consistent with gastric placement of the NG tube. This finding supports proper tube positioning and function.

D. Abdominal rigidity may indicate that gastric contents are not being adequately decompressed, suggesting the NG tube is obstructed or not functioning properly. This is an abnormal and concerning finding requiring immediate attention.

A. The provider should renew the prescription for restraints every 48 hr. B. The nurse should pad the bony prominences. C. The nurse should tie the restraints using a square knot. D. The nurse should remove the restraints every 2 hr. E. The provider's prescription should include the type of restraint to use.

Correct Answer is ["B","D","E"]

Explanation

A. The provider should renew the prescription for restraints every 24 hours, not 48 hours. This ensures regular evaluation of the need for continued restraint use.

B. Padding bony prominences helps prevent skin breakdown and injury from the restraints.

C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in case of emergency.

D. Restraints should be released every 2 hours (or as specified by the provider) to assess and provide care for the client's needs and to prevent complications such as skin breakdown or circulation impairment.

E. The provider's prescription should specify the type of restraint to be used, the reason for use, the duration, and any other relevant details to ensure appropriate and safe application.

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Exhibits A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Exhibits

A nurse is planning care for a newly admitted client. Which of the following interventions should the nurse plan to take first?