The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours.

An older client who is receiving packed red blood cells on the third day postoperatively for colon resection.

An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery.

An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.

Answer and Explanation

The Correct Answer is B

A)   Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B)   Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C)   Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D)   Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.

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Correct Answer is C

Explanation

Imbalanced Nutrition: less than body requirements would be the nursing problem with the highest priority for an adolescent with anorexia nervosa. Anorexia nervosa is characterized by a severe restriction of food intake leading to a significantly low body weight, which can have serious physical and psychological consequences. Therefore, addressing the client's malnutrition and promoting adequate nutrition intake is crucial to prevent further complications. Disturbed Body Image, Interrupted Family Processes, and Noncompliance with treatment regimen are important nursing problems to address, but they are secondary to the client's malnutrition.

A. Tingling on tongue or lips. B. Episodes of shivering. C. Salty taste in the mouth. D. Difficulty breathing.

Correct Answer is A

Explanation

A.Tingling on the tongue or lips is an early sign of an allergic reaction to the contrast dye used during an intravenous pyelogram. This type of reaction can quickly progress to more severe symptoms, such as difficulty breathing and anaphylaxis, so it is crucial to recognize and respond to it promptly.

B. Episodes of shivering: Shivering is not typically an early sign of an allergic reaction to contrast dye. It might indicate a reaction to temperature or anxiety but is not as immediately concerning as symptoms of an allergic reaction.

C. Salty taste in the mouth: A salty or metallic taste is a common and benign side effect of the contrast dye and is not indicative of an adverse reaction.

D. Difficulty breathing: Difficulty breathing is a severe and later sign of an allergic reaction. By the time this symptom appears, the reaction has progressed and immediate intervention is necessary.

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The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is C

Explanation

An adult client is admitted for severe pain in his side and back and is sent for an intravenous pyelogram. Which report from the client is the earliest indication to the nurse that the client is experiencing an adverse reaction to this procedure?

Correct Answer is A

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

A client with unilateral hearing loss is admitted for a scheduled surgery. Which technique should the nurse use to provide education about pain relief options?

The parent of a child born with a myelomeningocele asks the nurse, "What did I do to deserve this?" Which response is most helpful?

The nurse is caring for a client newly diagnosed with emphysema. The nurse should prioritize which potential complication?

The school nurse is called to the soccer field because a child has a nose bleed (epistaxis). In which position should the nurse place the child?

After receiving a change of shift report for clients on a medical surgical unit, which activity should the nurse delegate to the practical nurse (PN)?

The nurse is preparing to administer a suspension ampicillin labeled, 250 mg/5 mL, to a child with impetigo. The prescription is for 500 mg four times a day. How many mL should the child receive per day? (Enter numeric value only.)

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)