Which patient should the nurse assess first after receiving a change-of-shift report?

A patient with a scheduled physical therapy session in 1 hour.

A patient with a routine follow-up appointment for a non-urgent condition.

A patient with altered mental status and confusion.

A patient with moderate pleuritis and requesting pain medication.

Answer and Explanation

The Correct Answer is C

A. While this patient is scheduled for a physical therapy session, it is not an urgent concern that would require immediate attention.
B. A routine follow-up appointment for a non-urgent condition can be managed at a later time and does not take priority over more acute concerns.
C. A patient with altered mental status and confusion should be assessed first. This could indicate a serious underlying issue such as infection, hypoxia, or a neurological condition. Altered mental status in any patient warrants immediate attention to prevent further complications.
D. Although the patient with pleuritis is in pain, moderate pleuritis is typically not an urgent condition, and pain management can be provided after more pressing concerns are addressed.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Soap-suds enemas are not recommended for clients with ulcerative colitis because they can irritate the colon and worsen symptoms. Enemas should be used cautiously, if at all, and only when medically indicated.
B. Soaking in a sitz bath can help soothe perianal discomfort, but it is not the most effective intervention for protecting the skin from diarrhea-related irritation. Barrier creams are a more direct way to protect the skin from further damage.
C. Wiping the perianal area with warm water and applying a barrier cream is an appropriate and effective intervention to protect the skin. The warm water is gentle, and the barrier cream provides a protective layer that helps prevent skin breakdown from frequent contact with stool.
D. Cleansing with an antimicrobial scrub and vigorously drying the perianal area could cause further irritation and damage to already sensitive skin. The focus should be on gentle cleansing and protecting the skin with a barrier cream.

A. "A hiatal hernia might increase your risk for GERD." B. "A hiatal hernia might increase your risk for stomach cancer." C. "A hiatal hernia might increase your risk for intestinal cancer." D. "A hiatal hernia might increase your risk for lung disease."

Correct Answer is A

Explanation

A. A hiatal hernia can increase the risk of gastroesophageal reflux disease (GERD) because the hernia can cause the lower esophageal sphincter to malfunction, leading to the backflow of stomach acid into the esophagus. This increases the risk of reflux symptoms, such as heartburn and regurgitation.
B. There is no direct link between a hiatal hernia and an increased risk for stomach cancer. While long-term GERD can contribute to other esophageal issues, such as Barrett’s esophagus, it does not directly cause stomach cancer.
C. A hiatal hernia does not increase the risk of intestinal cancer. Its primary association is with GERD and related complications.
D. A hiatal hernia is not associated with an increased risk for lung disease. However, severe GERD symptoms can cause respiratory issues such as aspiration pneumonia, but this is not the same as directly increasing the risk of lung disease.

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Which patient should the nurse assess first after receiving a change-of-shift report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is creating a plan of care to maintain the skin integrity of a client who experiences frequent diarrhea due to ulcerative colitis. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

A nurse is caring for a client in the primary care office who has a recent diagnosis of a hiatal hernia. Which of the following new information will be beneficial for the nurse to relay to the client?

Correct Answer is A

Explanation

A nurse is preparing to administer meperidine 35 mg IM to a client every 6 hr PRN for pain. Available is meperidine injection 75 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

A nurse is assessing a client who is receiving total parenteral nutrition (TPN) therapy via an infusion pump. Which of the following actions should the nurse take?

A nurse is teaching student nurses about different types of medical conditions that affect the gastrointestinal system, when a student asks her about the cause of esophageal varices. What is an appropriate answer by the nurse when asked about a potential cause of esophageal varices?

A nurse is caring for a client who is receiving total parenteral nutrition and develops refeeding syndrome. The nurse should expect which of the following laboratory findings?

A nurse is assessing a client who has peptic ulcer disease. Which of the following findings should the nurse identify as the priority?

A patient with anorexia nervosa shows signs of malnutrition and is prescribed parenteral nutrition. If the client develops refeeding syndrome, what laboratory tests does the nurse expect the healthcare provider to order? (Select all that apply.)

Which of the following statements about strictureplasty is correct?