Á nurse is caring for a client who is being admitted for an acute exacerbation of ulcerative colitis. Which of the following actions should the nurse take first?
Obtain a dietary history from the client.
Review the client's electrolyte values.
Investigate the client's emotional concerns.
Check the client's perianal skin integrity.
The Correct Answer is B
A. Obtaining a dietary history is relevant for ongoing management but is not the initial priority.
B. Reviewing electrolyte values is essential because exacerbations of ulcerative colitis can lead to severe fluid and electrolyte imbalances, which need prompt correction.
C. Investigating emotional concerns is important but does not take precedence over addressing potential electrolyte imbalances that can be life-threatening.
D. Checking perianal skin integrity is relevant for comfort but is not the priority in stabilizing the client during an acute exacerbation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The location of burns on the face, neck, and upper extremities is critical as it can compromise the airway, making it a priority.
B. Age is important for overall risk assessment, but airway compromise takes precedence.
C. The cause of the burn (e.g., chemical, electrical) impacts treatment but is secondary to addressing airway risks in this scenario.
D. Associated medical history provides context but does not supersede the immediate concerns related to the burn location and airway.
Correct Answer is B
Explanation
A. Ambulating soon after surgery is encouraged to promote circulation and decrease the risk of VTE.
B. Massaging the legs is unsafe, as it can dislodge any existing clot, potentially leading to a pulmonary embolism.
C. Elevating the feet helps improve venous return and is a safe practice to reduce VTE risk.
D. Flexing the ankles is part of exercises that help promote blood flow and reduce clot formation risk.
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