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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. A 33-year-old with burns to the back and shoulders. B. A 32-year-old with burns on the hands and face. C. A 42-year-old with burns on both legs. D. A 25-year-old with a burn on the left arm.

Correct Answer is B

Explanation

Choice A rationale
A 33-year-old with burns to the back and shoulders. While this patient’s injuries are serious, they are not immediately life-threatening. The back and shoulders are not vital areas, and while pain management and wound care will be necessary, this patient’s situation is not as urgent as others.
Choice B rationale
A 32-year-old with burns on the hands and face. This patient should be attended to first. Burns on the hands and face are more serious due to the high risk of infection and the potential for complications such as impaired breathing if the airway swells or becomes blocked due to the burns. Immediate treatment can help to prevent these complications.
Choice C rationale
A 42-year-old with burns on both legs. While these burns are serious, they are not immediately life-threatening. The patient will need pain management and wound care, and may have mobility issues, but their vital organs are not directly impacted by the burns.
Choice D rationale
A 25-year-old with a burn on the left arm. This patient, while in need of treatment, is not the highest priority. A burn on the arm, while painful and requiring treatment, is not as potentially serious or life-threatening as burns to the face, hands, or major portions of the body.

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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

Following an explosion at a local chemical lab, several people have sustained burns and are now in the triage area. Which patient should be attended to first?

Correct Answer is B

Explanation

A patient with acute pancreatitis is in severe pain. Which position should the nurse suggest the patient to assume?

The nursing assistant is delivering patient meals. What meal should the nurse expect to be delivered to a patient who had gastric bypass surgery the day before?

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

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?

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

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

A nurse is helping a postoperative patient following a total hip arthroplasty into a supine position. Which of the following actions is appropriate to prevent hip dislocation?

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