The nurse has been assigned to provide care for four clients on the day shift. Aher hearing the 1500 hand-off report, which client does the nurse prioritize to see first?
A client admitted with pancreatitis who is requesting pain medication
A client post a liver biopsy who has tachycardia and is restless
A client admitted with ulcerative Colts who is requesting an anti-diarrhea
A client postop day with dark red drainage the size of a dime on the dressing
The Correct Answer is B
A. A client admitted with pancreatitis who is requesting pain medication: While pancreatitis causes severe pain, this is not the highest priority. Pain management is important, but it does not indicate an immediate life-threatening issue.
B. A client post a liver biopsy who has tachycardia and is restless: Tachycardia and restlessness following a liver biopsy may indicate internal bleeding due to liver puncture. The liver is highly vascular, and hemorrhage is a serious complication requiring immediate assessment.
C. A client admitted with ulcerative colitis who is requesting an anti-diarrheal: While diarrhea is distressing, this is not life-threatening. The client can be seen after addressing the higher-priority client.
D. A client postop day 1 with dark red drainage the size of a dime on the dressing: Small amounts of dark red drainage are expected postoperatively. This client does not require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["25"]
Explanation
Total volume to be infused = 50 mL
Infusion rate = 2 mL/min
Time required = Total volume / Infusion rate
= 50 mL ÷ 2 mL/min
= 25 minutes
Correct Answer is C
Explanation
A. Stoma oozing red drainage: Some drainage is expected postoperatively.
B. Rosebud-like stoma orifice: This is a normal appearance of a healthy stoma.
C. Purplish colored stoma: A purplish stoma indicates ischemia or poor perfusion and requires immediate intervention.
D. Shiny, moist stoma: This is a normal finding for a stoma.
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