Which of the following clients should be seen first?
A patient hospitalized with acute pancreatitis and is sitting in a high Fowler’s position leaning over the bedside table.
A patient who had bariatric surgery and is reporting shoulder pain and heart racing.
A patient who is one day post-op after an intestinal resection and colostomy, and has no effluent in the bag.
A patient with cirrhosis and is reporting loose stools.
The Correct Answer is B
Choice A rationale
A patient with acute pancreatitis sitting in a high Fowler’s position leaning over the bedside table may be experiencing discomfort, but it is not an immediate life-threatening situation.
Choice B rationale
A patient who had bariatric surgery and is reporting shoulder pain and heart racing could be experiencing complications such as a pulmonary embolism, which is a life-threatening condition. This patient should be seen first.
Choice C rationale
A patient who is one-day post-op after an intestinal resection and colostomy and has no effluent in the bag may need further assessment, but it is not an immediate life-threatening situation.
Choice D rationale
A patient with cirrhosis reporting loose stools may be uncomfortable, but it is not an immediate life-threatening situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Based on the provided exhibits, the client is most likely experiencingBacterial Meningitis. This is indicated by symptoms such as severe headache, fever, sensitivity to light, nuchal rigidity, and the presence of Neisseria meningitidis in the cerebrospinal fluid with elevated white blood cell count and lactic acid levels.
The two actions the nurse should take to address this condition are:
- Anticipate administering antibiotic therapy- This is crucial as the client’s culture and sensitivity test indicates the presence of Neisseria meningitidis, which requires antibiotic treatment.
- Place the client on droplet precautions- Since Neisseria meningitidis can be spread through respiratory droplets, it is important to implement droplet precautions to prevent the spread of infection.
The two parameters the nurse should monitor to assess the client’s progress are:
- Level of consciousness- Monitoring for changes in the client’s level of consciousness can indicate the effectiveness of the treatment and the progression of the disease.
- Increased intracranial pressure- Signs of increased intracranial pressure can include changes in vital signs, level of consciousness, and the presence of headache or vomiting. Monitoring these signs is important in the management of bacterial meningitis.
Correct Answer is C
Explanation
A gastric residual volume of 10ml is not considered high. The client is receiving 60ml/hr of feeding, which is within normal limits. Therefore, the nurse should continue the feeding as ordered.
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