The nurse has received a report for the following patients. Which patient should be seen first?

89-year-old with dementia and NG tube with continuous tube feeding

73-year old with hypoactive bowel sounds one day post cholecystectomy.

43 year old with anorexia and nausea for two days who is tolerating a clear liquid diet

65 year old with who has dysphagia after suffering from a stroke who is NPO

Answer and Explanation

The Correct Answer is D

A. 89-year-old with dementia and NG tube with continuous tube feeding: While this patient requires monitoring, continuous tube feeding is routine, and there is no indication of immediate distress.

B. 73-year-old with hypoactive bowel sounds one day post-cholecystectomy: Hypoactive bowel sounds are expected after surgery, particularly after abdominal procedures. This does not indicate an emergency.

C. 43-year-old with anorexia and nausea for two days who is tolerating a clear liquid diet: This patient’s condition is stable, and nausea is resolving, making them a lower priority.

D. 65-year-old who has dysphagia after suffering from a stroke who is NPO: Dysphagia (difficulty swallowing) increases the risk of aspiration pneumonia, which can be life-threatening. This patient should be assessed first to ensure their airway is protected.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Avoid using your fingers to open the mouth: While this is a safety measure to prevent injury, it is not the most important intervention.

B. Apply moisturizer to the oral mucosa and lips: While this is beneficial for comfort, preventing aspiration and maintaining airway patency are higher priorities.

C. Brush the teeth with a soft-bristled toothbrush: Oral hygiene is important, but the highest priority is preventing aspiration.

D. Use a toothbrush with a suction attachment: Suction prevents the accumulation of oral secretions, reducing the risk of aspiration pneumonia in a sedated patient.

A. "This new room has negative pressure and does six to twelve air changes an hour and disposes the air outside to reduce the infection potential in other patients. I also have to wear this surgical mask" B. "It sounds like you have some questions about your new diagnosis. What are you most concerned about?" C. "Tuberculosis can seriously impair the lungs and requires a long course of antibiotics to treat it D. “Tuberculosis is a small particle that can spread through the air. This new room has a special filter that reduces the spread of the bacteria through the air."

Correct Answer is D

Explanation

While this provides technical information, the surgical mask part is incorrect; the nurse should wear an N95 respirator, not a surgical mask.

B. "It sounds like you have some questions about your new diagnosis. What are you most concerned about?"

While this is a therapeutic communication technique, it does not directly answer the patient's question about airborne precautions.

C. "Tuberculosis can seriously impair the lungs and requires a long course of antibiotics to treat it."

This statement provides disease information but does not explain why airborne isolation is necessary.

D. "Tuberculosis is a small particle that can spread through the air. This new room has a special filter that reduces the spread of the bacteria through the air."

This provides a concise and accurate explanation of airborne precautions in terms the patient can understand.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

The nurse has received a report for the following patients. Which patient should be seen first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

Correct Answer is D

Explanation

The nurse is providing care to a patient who has tested positive for tuberculosis. The patient is moved into an airborne isolation room and the patient asks. "Why do I need to be moved into this new room?" How should the nurse respond?

Correct Answer is D

Explanation

During a health history interview, a client tells the nurse that they do not feel that they completely empty the bladder when they void. How would the nurse report this findings to the provider?

A nurse enters a patient's room and finds that the patient has fallen on the way to the bathroom. What action should be implemented first?

A student nurse is assessing their patient who is NPO due to a recent surgery. The provider comes in the room to see the patient and states that the patient is cleared to start a full liquid diet. What is the best action by the student nurse?

The nurse is assessing the patient's output for the shift. What finding is most concerning?

The following procedures have been ordered and implemented for a hospitalized patient. Which procedure carries the greatest risk for a healthcare-associated infection?

The student nurse has identified that the patient is a risk for falling and has implemented fall precautions. What action taken by the student would require further teaching from the clinical faculty?

The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?