A nurse is caring for a client who has just returned from the Post-Anesthesia Care Unit (PACU) with an intravenous (IV) fluid infusion and a nasogastric (NG) tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

The coping ability of the client

The client's bowel sounds

The patency of the NG tube

The surgical dressing

None

Answer and Explanation

The Correct Answer is C

Choice A reason:
Assessing the coping ability of the client is important, but it is not the immediate priority following abdominal surgery. The nurse must first ensure that the client's physiological needs are met and that there are no immediate postoperative complications.

Choice B reason:
While monitoring bowel sounds can provide valuable information about the return of gastrointestinal function, it is not the most immediate concern postoperatively. The nurse should prioritize assessments that ensure the client's safety and immediate physiological stability.

Choice C reason:
Ensuring the patency of the NG tube is the priority assessment. A patent NG tube is crucial for decompressing the stomach, preventing nausea and vomiting, and reducing the risk of aspiration, which can be life-threatening. It is also essential for the removal of gastric secretions and to prevent abdominal distention, which can compromise the surgical site and lead to complications such as wound dehiscence.

Choice D reason:
Assessing the surgical dressing is important to check for signs of bleeding or infection. However, the patency of the NG tube takes precedence as it is directly related to the client's airway and breathing, which are always the top priorities in postoperative care.

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Correct Answer is B

Explanation

Choice A reason:
Asking about the identity of the assailant, while important for legal purposes, does not contribute to the immediate medical care of the client. The priority is to address potential health issues, such as exposure to HIV.

Choice B reason:
The timing of the assault is critical because it determines the eligibility for PEP. PEP should be initiated as soon as possible, ideally within 2 hours, but it can be effective up to 72 hours after exposure. Knowing the exact time of the assault helps healthcare providers act swiftly to mitigate the risk of HIV transmission.

Choice C reason:
While knowing where the assault occurred can provide context and may be relevant for legal proceedings, it does not influence the immediate medical treatment plan for potential HIV exposure.

Choice D reason:
Consent to involve law enforcement is a separate issue from medical treatment. While it's important to respect the client's wishes regarding reporting, it does not impact the decision-making process regarding HIV prophylaxis.

A. Examine the skin for generalized urticaria. B. Monitor the mouth for signs of xerostomia. C. Review laboratory test results for low hemoglobin. D. Observe for signs of infection.

Correct Answer is B

Explanation

Choice A reason:
Generalized urticaria, or hives, is not a common side effect of radiation therapy for lung cancer. While skin reactions can occur, they are usually localized to the area being treated. Urticaria might be a sign of an allergic reaction, which would require immediate attention, but it is not typically associated with radiation therapy¹.

Choice B reason:
Xerostomia, or dry mouth, is a common side effect of radiation therapy, especially when the radiation field includes salivary glands. For lung cancer patients, if the radiation field is near the neck or upper chest, it could potentially affect salivary gland function. Monitoring for xerostomia is important because it can lead to difficulties in speaking, eating, and swallowing, and it increases the risk for dental problems².

Choice C reason:
While reviewing laboratory test results for low hemoglobin is an important part of nursing care, it is not specific to radiation therapy for lung cancer. Low hemoglobin could be related to the cancer itself or a side effect of other treatments like chemotherapy. It is important to monitor, but not the primary action related to radiation therapy³.

Choice D reason:
Observing for signs of infection is a general nursing responsibility for all patients, not specific to those receiving radiation therapy for lung cancer. However, if the patient's immune system is compromised due to the cancer or other treatments, vigilance for infection is heightened.

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A nurse is caring for a client who has just returned from the Post-Anesthesia Care Unit (PACU) with an intravenous (IV) fluid infusion and a nasogastric (NG) tube in place following abdominal surgery. Which of the following data is the priority for the nurse to assess?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following questions is most important to ask a client who might have been exposed to HIV after being sexually assaulted?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving radiation therapy to treat lung cancer. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?

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