The nurse has been assigned to provide care for four clients on the day shift. Aher hearing the 1500 hand-off report, which client does the nurse prioritize to see first?

A client admitted with pancreatitis who is requesting pain medication

A client post a liver biopsy who has tachycardia and is restless

A client admitted with ulcerative Colts who is requesting an anti-diarrhea

A client postop day with dark red drainage the size of a dime on the dressing

Answer and Explanation

The Correct Answer is B

A. A client admitted with pancreatitis who is requesting pain medication: While pancreatitis causes severe pain, this is not the highest priority. Pain management is important, but it does not indicate an immediate life-threatening issue.

B. A client post a liver biopsy who has tachycardia and is restless: Tachycardia and restlessness following a liver biopsy may indicate internal bleeding due to liver puncture. The liver is highly vascular, and hemorrhage is a serious complication requiring immediate assessment.

C. A client admitted with ulcerative colitis who is requesting an anti-diarrheal: While diarrhea is distressing, this is not life-threatening. The client can be seen after addressing the higher-priority client.

D. A client postop day 1 with dark red drainage the size of a dime on the dressing: Small amounts of dark red drainage are expected postoperatively. This client does not require immediate attention.

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Correct Answer is B

Explanation

peritonitis are present. Treating the underlying cause (perforation) is more urgent than lowering the fever.

B. Notify the healthcare provider: A hard, rigid abdomen with fever indicates possible perforation and peritonitis, which is a medical emergency. The provider must be notified immediately for urgent intervention.

C. Prepare to administer an enema: Enemas are contraindicated in acute diverticulitis due to the risk of perforation.

D. Continue to monitor the client closely: While continued monitoring is always necessary, immediate action (calling the provider) is critical when signs of peritonitis are present.

A. "Take pain relief medication such as acetaminophen to relieve discomfort associated with ascites.” B. "Avoid high-sodium foods such as canned soups/vegetables, processed meats and prepackaged from diners C. "Ensure that you sat three large meals per day to keep your calories up." D. “Increase your activity as much as possible. You need to remain active.”

Correct Answer is B

Explanation

A. "Take pain relief medication such as acetaminophen to relieve discomfort associated with ascites." Acetaminophen is hepatotoxic and should be avoided in clients with liver disease.

B. "Avoid high-sodium foods such as canned soups/vegetables, processed meats, and prepackaged foods." Sodium restriction helps prevent fluid retention and ascites in clients with cirrhosis. Processed and canned foods are high in sodium and should be avoided.

C. "Ensure that you eat three large meals per day to keep your calories up." Clients with cirrhosis should eat small, frequent meals to avoid hypoglycemia and excessive strain on the liver.

D. "Increase your activity as much as possible. You need to remain active." While moderate activity is encouraged, clients with cirrhosis often have fatigue and muscle wasting. Overexertion can worsen their condition.

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The nurse has been assigned to provide care for four clients on the day shift. Aher hearing the 1500 hand-off report, which client does the nurse prioritize to see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client diagnosed with acute diverticulitis is complaining of severe abdominal pain. On assessment, the nurse finds a hard, rigid abdomen and a temperature of 102 F. Which of the following is the highest priority?

Correct Answer is B

Explanation

A nurse is preparing discharge instructions for a client who has cirrhosis of the liver. Which of the following statements should be included in the education?

Correct Answer is B

Explanation

The nurse is facilitating a support group for clients diagnosed with inflammatory Bowel Disease. Which information is most important for the nurse to share with this group? Select All that Apply

A nurse is caring for a client who has end-stage liver disease and a recent diagnosis of thrombocytopenia. Which of the following statements provides the best recommendation to prevent complications of bleeding?

A client with end stage liver disease, cirrhosis, and ascites is scheduled for a paracentesis. Which of the following interventions can be anticipated related to care of this patient?

The nurse is completing preoperative teaching on a client. Which of the following response should the nurse offer to a client who asks why he's having a total colectomy with ileostomy formation to treat his ulcerative colitis?

The nurse is caring for a client with cirrhosis, portal hypertension, and encephalopathy. Which of the following orders would be anticipated to lower the ammonia level? (Select All that Apply)

A nurse is providing discharge instructors to a client with hepatitis B. Which of the following statements should be included in the teaching?

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