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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.
B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.
C. Not having a bowel movement since prior to admission is not an urgent concern in the
immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.
D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.
Correct Answer is A
Explanation
A.
A. The infant's eyes turn toward the light - This is the expected finding known as the "fixation reflex," where infants naturally turn their eyes toward a light source.
B. The infant's head turns away from the light - This would not be an expected finding during a vision screening; it may suggest a different reflex or issue.
C. The infant's eyes remain focused toward the floor - This would not be an expected finding during a vision screening; it may suggest a different visual or developmental concern.
D. The infant closes their eyes - Closing the eyes in response to light is not the typical response during a vision screening for infants.
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