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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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale
During the fluid resuscitation phase of burn management, the primary goal is to restore circulating volume and preserve vital organ and tissue perfusion. One of the most effective methods for assessing the results of fluid resuscitation is monitoring urine output. A urine output greater than 0.5 mL/kg/hr is generally considered an indicator of adequate fluid resuscitation.
Choice B rationale
While clear bilateral breath sounds are an important part of overall patient assessment, they are not the best method for assessing the results of fluid resuscitation in burn management.
Choice C rationale
Serum hemoglobin is not the best indicator for assessing the results of fluid resuscitation in burn management. While it can provide information about the patient’s overall health and blood volume, it does not directly reflect the adequacy of fluid resuscitation.
Choice D rationale
A heart rate of 122/min could indicate a response to pain, anxiety, or inadequate fluid resuscitation. However, it is not the best method for assessing the results of fluid resuscitation in burn management.

A. Place the patient in the Trendelenburg position. B. Change the patient’s position slowly. C. Reduce the oxygen flow. D. Increase the IV fluid flow.

Correct Answer is B

Explanation

Choice A rationale
The Trendelenburg position, which involves laying the patient flat on their back with their legs elevated higher than their head, is not recommended for patients with septic shock. This position can increase intracranial pressure and does not improve circulation or oxygenation.
Choice B rationale
Changing the patient’s position slowly is important in managing an elderly patient with septic shock. Rapid changes in position can cause a drop in blood pressure (orthostatic hypotension), which can lead to falls or decreased perfusion to vital organs.
Choice C rationale
Reducing the oxygen flow is not recommended for patients with septic shock. These patients often have difficulty with oxygenation and may require supplemental oxygen to maintain adequate oxygen levels.
Choice D rationale
Increasing the IV fluid flow is part of the initial management of septic shock to restore perfusion, but it should be done based on careful assessment and monitoring of the patient’s response to fluids. Overzealous fluid resuscitation can lead to fluid overload and complications such as pulmonary edema.

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Which of the following clients should be seen first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?

Correct Answer is A

Explanation

The nurse is caring for an 85-year-old patient with septic shock. What should the nurse consider when repositioning this patient?

Correct Answer is B

Explanation

A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?

A nurse is attending to a client experiencing hypovolemic shock. What findings should the nurse anticipate?

The nurse is caring for a patient with chronic liver failure. Which medication order should the nurse querry

A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest. What is the primary risk to the client?

A nurse is reinforcing discharge teaching with a client who has pulmonary edema and is about to start taking furosemide. Which of the following instructions should the nurse include?

A nurse is preparing to administer clindamycin palmitate 225 mg PO to a client. Available is clindamycin palmitate oral suspension 75 mg/5 mL. How many ml’s should the nurse administer?

A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?