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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
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
Choice B rationale
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
Choice C rationale
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
Choice D rationale
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.

A. Prepare IV morphine for administration by the RN. B. Apply ice to the burned area. C. Apply a neutralizing agent. D. Remove the patient’s clothing.

Correct Answer is D

Explanation

Choice A rationale
While pain management is important in burn care, the first action should be to stop the burning process. Administering IV morphine does not achieve this.
Choice B rationale
Applying ice to a burn can cause vasoconstriction and may increase tissue damage. It is not the first action to stop the burning process.
Choice C rationale
Applying a neutralizing agent is not the first action in chemical burn management. The priority is to remove the chemical from contact with the skin.
Choice D rationale
Removing the patient’s clothing is the first action in burn management. This prevents further contact of the chemical with the skin and stops the burning process.

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Which of the following clients should be seen first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction. The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage. Which of the following statements is the best response from the nurse?

Correct Answer is A

Explanation

A patient with chemical burns to the chest and abdomen is admitted to the emergency department. The registered nurse begins to flush the area with sterile saline. What is the first action the LPN should take to stop the burning process?

Correct Answer is D

Explanation

A nurse leader is discussing possible continuing education opportunities with other staff members. Which of the following actions should the nurse leader recommend to maintain clinical competence?

The nurse is reviewing orders for a patient in anaphylactic shock. Which medications should the nurse plan to administer first?

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?

A nurse is attending to a client who has suffered a basal skull fracture. During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril. What should be the nurse’s immediate action?

A nurse is providing care to multiple patients in a hospital setting. Which patient is at the highest risk for developing hypoglycemia?

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 during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?

A nurse is collecting data from a client who has peptic ulcer disease. Which of the following findings is a manifestation of gastrointestinal perforation?