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 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.
Correct Answer is B
Explanation
Choice A rationale
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice B rationale
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
Choice C rationale
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice D rationale
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.
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