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 D

Explanation

The ability to effectively communicate and provide accurate information can be impacted by external factors such as noise, distractions, or an unfamiliar environment. By assessing the surroundings, the nurse can identify and address any potential barriers to communication.

Once the nurse has addressed any environmental factors that may be hindering communication, they can proceed with other strategies to facilitate the health history assessment. This may include providing a printed healthcare assessment form to assist the client in organizing their thoughts or deferring the assessment until the client is less anxious.

Asking the family member to answer the questions should be considered if the client is unable to provide accurate information or is cognitively impaired. However, it is important to first address any environmental factors and attempt to engage the client directly in the assessment process.

A. Disturbed Body Image. B. Interrupted Family Processes. C. Imbalanced Nutrition: less than body requirements. D. Noncompliance with treatment regimen.

Correct Answer is C

Explanation

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.

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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

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

Correct Answer is D

Explanation

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

Correct Answer is C

Explanation

A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?

A client who is having gastrointestinal (GI) difficulties is undergoing diagnostic procedures. The client asks the nurse about the difference between ulcerative colitis and Crohn's disease. Which information should the nurse offer?

Patient Data What other treatments might be helpful for this client? Select all that apply.

A client who weighs 110 pounds receives a prescription for dalteparin 150 units/kg subcutaneously daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

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

Review H and P and nurse's notes. What are the first four actions that the nurse should take?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?