After receiving report on an inpatient acute care unit, which client should the nurse assess first?

The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity.

The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds.

The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid.

The client with an obstruction of the large intestine who is experiencing abdominal distention.

Answer and Explanation

The Correct Answer is A

A.   Abdominal rigidity in a client with a bowel obstruction due to a volvulus indicates possible peritonitis, which is a medical emergency.
B.   Paralytic ileus with absent bowel sounds is concerning but not immediately life- threatening.
C.   A nasogastric tube draining greenish fluid is expected in small bowel obstruction.

D. Abdominal distention in large intestine obstruction is concerning but less urgent than potential peritonitis.

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Correct Answer is D

Explanation

A. While physical activity is important for overall health, it may not directly address constipation. Increasing fluid and fiber intake is a more specific intervention.

B. Stool softeners can be helpful, but dietary modifications should be attempted first before resorting to medications.
C. Gas-producing foods may not be directly related to constipation. The focus should be on promoting regular bowel movements through diet and hydration.
D. Increasing fluid and fiber intake is a recommended first-line approach for managing constipation in older adults.

A. The client's need for pain medication should be determined. B. The nurse manager should be updated on the client's status. C. The client's status should be conveyed to the chaplain. D. The impending signs of death should be documented.

Correct Answer is A

Explanation

A. Ensuring comfort during the dying process is paramount in end-of-life care. Assessing and managing pain promptly supports quality of life and dignity in the client's final moments.
B. The nurse manager should be updated on the client's status. While communication with the nurse manager is important, it is not the immediate priority when a client is experiencing discomfort or pain.
C. The client's status should be conveyed to the chaplain. Involving spiritual care is important but secondary to addressing any immediate physical comfort needs of the client.
D. The impending signs of death should be documented. Documentation is important, but it is a secondary priority to the direct care and comfort needs of the client.

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After receiving report on an inpatient acute care unit, which client should the nurse assess first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has constipation. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, which priority action should the nurse implement?

Correct Answer is A

Explanation

What 2 orders should the nurse complete first?

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