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 important, immediate assignment to a COVID-19 area is secondary to infection control precautions.
B. Proper handling of the specimen is essential but secondary to immediate safety measures.
C. Starting antiviral drugs would only occur after a positive test result.

D. Maintaining a 6 feet distance and wearing appropriate PPE is the most important action to prevent transmission of the virus.

A. Tell the child he will have to have a shot instead. B. Hide the medication in a large dish of ice cream. C. Tell the child it is candy. D. Offer the child a choice of taking the medication with juice or water.

Correct Answer is D

Explanation

A. Threatening the child with a shot may create anxiety and fear, making cooperation even more challenging.
B. Hiding medication in food without the child's knowledge can lead to mistrust and may not be safe, as the child may not consume the entire dose.
C. Misleading the child about the nature of the medication is not appropriate. It can lead to confusion and mistrust when the child realizes that it is not candy.

D. Providing choices empowers the child and makes the process of taking medication less intimidating. It also helps in engaging the child in their own care, making them feel more in control.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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