The nurse has received a report for the following patients. Which patient should be seen first?

89-year-old with dementia and NG tube with continuous tube feeding

73-year old with hypoactive bowel sounds one day post cholecystectomy.

43 year old with anorexia and nausea for two days who is tolerating a clear liquid diet

65 year old with who has dysphagia after suffering from a stroke who is NPO

Answer and Explanation

The Correct Answer is D

A. 89-year-old with dementia and NG tube with continuous tube feeding: While this patient requires monitoring, continuous tube feeding is routine, and there is no indication of immediate distress.

B. 73-year-old with hypoactive bowel sounds one day post-cholecystectomy: Hypoactive bowel sounds are expected after surgery, particularly after abdominal procedures. This does not indicate an emergency.

C. 43-year-old with anorexia and nausea for two days who is tolerating a clear liquid diet: This patient’s condition is stable, and nausea is resolving, making them a lower priority.

D. 65-year-old who has dysphagia after suffering from a stroke who is NPO: Dysphagia (difficulty swallowing) increases the risk of aspiration pneumonia, which can be life-threatening. This patient should be assessed first to ensure their airway is protected.

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Correct Answer is C

Explanation

A. Check the patient's urinalysis. While a urinalysis may provide useful information (e.g., infection, kidney function), it does not address the immediate concern—significantly decreased urine output despite adequate intake. The priority is to determine urinary retention first.

B. Notify the provider of the patient's pain 7/10. While pain management is important, the more critical issue is the drastically low urine output (150mL in 12 hours), which could indicate acute urinary retention or renal dysfunction. Addressing the urinary issue should come first.

C. Perform a bladder scan. The low urine output (150mL in 12 hours) despite sufficient intake (2150mL) suggests potential urinary retention. A bladder scan is the quickest and least invasive way to determine if the patient has a full bladder that needs intervention (e.g., catheterization). This is the priority before further testing or notifying the provider.

D. Assess the daily weight. Daily weight monitoring is helpful for fluid status assessment, especially in cases of heart failure or kidney disease, but it is not the most immediate priority. The primary concern is whether the patient has urinary retention, which requires urgent evaluation.

A. "Void every four hours even if you feel like you do not need to urinate." B. "You should perform Kegel exercises several times a day." C. "When possible, you should try to take a tub bath instead of a shower." D. “It is important to clean front to back during bathing and after using the restroom."

Correct Answer is D

Explanation

A. "Void every four hours even if you feel like you do not need to urinate." While frequent voiding is beneficial, forcing a rigid schedule is not necessary. The priority is voiding after intercourse and staying hydrated to flush bacteria.

B. "You should perform Kegel exercises several times a day." Kegel exercises strengthen the pelvic floor but do not prevent UTIs.

C. "When possible, you should try to take a tub bath instead of a shower." Soaking in a bath can introduce bacteria into the urethra, increasing UTI risk. Showers are recommended.

D. “It is important to clean front to back during bathing and after using the restroom.” Wiping front to back prevents the spread of bacteria from the perineal area to the urethra, a major cause of UTIs.

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Laboratory Test	Reference Range	Patient Results
White Blood Cells	5,000- 10,000/mm3	9,500/mm3
Neutrophil Count	2.500-8,000/mm3	5,200/mm3
HIV	Negative	Positive

The nurse has received a report for the following patients. Which patient should be seen first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is providing education to a female patient who has been diagnosed with recurrent urinary tract infections. What statement should the nurse include in the education?

Correct Answer is D

Explanation

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