The nurse is receiving hand-off report. Which of the following clients would the nurse assess first?
A client with an intestinal obstruction whose nasogastric tube has drained 150 mL in 8 hours
A client with ascites who has a respiratory rate of 26 and oxygen saturation level of 90%
A client with acute pancreatitis who has decreased breath sounds with increased crackles
A client with stable esophageal varices and a blood pressure of 92/45
The Correct Answer is A
Choice A reason: 150 mL NG drainage in 8 hours is low for obstruction, suggesting stability; it’s less urgent than respiratory compromise in other clients.
Choice B reason: Respiratory rate 26 and 90% saturation indicate distress in ascites, but crackles suggest fluid overload, less acute than pancreatitis’s pulmonary risk.
Choice C reason: Decreased breath sounds and crackles in pancreatitis signal pleural effusion or ARDS, a life-threatening complication, prioritizing immediate respiratory assessment.
Choice D reason: BP 92/45 with stable varices is concerning but not acutely unstable without bleeding signs, less critical than respiratory failure in pancreatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: Barrel chest develops in emphysema from chronic air trapping, overexpanding lungs and flattening the diaphragm, altering thoracic shape over years.
Choice B reason: Edema relates to right heart failure from cor pulmonale, a late emphysema complication, not a direct or universal finding after five years.
Choice C reason: Productive cough is typical in chronic bronchitis, not emphysema, which features alveolar destruction and minimal mucus, leading to dry cough instead.
Choice D reason: Dyspnea in emphysema results from alveolar loss reducing oxygen exchange, forcing compensatory rapid breathing, a core symptom even after five years.
Choice E reason: Clubbed fingers occur in chronic hypoxia from emphysema, as poor oxygenation over years triggers nail bed angiogenesis, a common late finding.
Correct Answer is ["A","B"]
Explanation
Choice A reason: Tachypnea occurs in left-sided heart failure as pulmonary edema from backpressure increases respiratory effort to oxygenate blood through fluid-filled alveoli.
Choice B reason: Cough in left-sided failure results from pulmonary congestion irritating airways, often producing frothy sputum as fluid leaks from capillaries into lungs.
Choice C reason: Jugular vein distention indicates right-sided heart failure, where systemic venous pressure rises, not left-sided, which affects lungs, not neck veins.
Choice D reason: Ascites, abdominal fluid buildup, stems from right-sided failure’s hepatic congestion, not left-sided failure’s pulmonary focus, making it unrelated here.
Choice E reason: Confusion may occur late in severe heart failure from hypoxia, but it’s not specific to left-sided failure’s early pulmonary symptoms like tachypnea.
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