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 A

Explanation

A. 46-year-old with a low neutrophil count: Neutrophils are essential for fighting infection. A low neutrophil count (neutropenia) significantly increases infection risk, making this the highest-priority patient.

B. 59-year-old seven days post abdominal surgery: While postoperative patients are at risk for infection, the greatest risk is within the first few days after surgery. By day seven, the risk decreases if no signs of infection are present.

C. 82-year-old with a history of leukemia ten years ago: While leukemia can affect the immune system, a history of leukemia from ten years ago is less concerning than an active condition causing immunosuppression.

D. 62-year-old on antibiotic therapy: While antibiotics can disrupt normal flora and increase the risk of infections like Clostridioides difficile, this risk is lower than that of a patient with neutropenia.

A. Output assessment B. General Status C. Stoma assessment D. Laboratory data

Correct Answer is B

Explanation

A. Output assessment: Liquid stool and gas output are expected findings for an ileostomy.

B. General status: The patient’s avoidance of looking at the ileostomy suggests poor adaptation and possible psychological distress, which may require intervention.

C. Stoma assessment: A red, moist, and protruding stoma is a normal finding.

D. Laboratory data: The patient’s potassium level is on the lower end but still within normal limits. There are no critical abnormalities.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

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

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Naxlex Comprehensive Predictor Exams

The nurse is providing care for the following patients. Which patient is at highest risk of developing an infection?

Correct Answer is A

Explanation

Correct Answer is B

Explanation

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