The nurse is assisting with the care of a client.
Complete the following sentence by using the lists of options.
The nurse is assisting with the plan of care for the client. The nurse should first assist with dropdownand then dropdown
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
• Initiating IV: The client shows signs of hypovolemia—tachycardia, hypotension, dry mucous membranes, and elevated BUN/creatinine—all of which indicate fluid deficit from vomiting and third-spacing due to the small-bowel obstruction. Immediate IV access is needed to begin fluid resuscitation and stabilize perfusion before any further interventions.
• Administering antibiotics: There is no evidence of infection requiring immediate antibiotic therapy—WBC count is normal, and there are no signs of peritonitis. Fluid resuscitation takes priority before any medication administration in a hemodynamically unstable client.
• Preparing for surgery: Although surgery may be needed later, the immediate priority is to stabilize circulation and decompress the bowel. The client is hypotensive and tachycardic, making preparation for surgery unsafe until volume status is corrected.
• Preparing to place a nasogastric tube: An NG tube is essential in small-bowel obstruction to decompress the bowel, relieve distention, reduce vomiting, and prevent perforation. After IV access is established for stabilization, NG tube placement becomes the next priority to reduce gastrointestinal pressure and prevent further complications.
• Weighing the client: This is not an urgent intervention and does not affect immediate treatment for a small-bowel obstruction. Stabilizing fluids and gastric decompression take precedence over baseline weight data.
• Monitoring intake and output: While important for ongoing assessment of hydration and renal perfusion, it is not the first or second priority. The client must first receive IV resuscitation and bowel decompression to prevent worsening shock.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The nurse should wear a mask during transport: While masks are required when providing care within close contact of the client, the nurse does not need to wear a mask during transport if maintaining distance. The primary protective measure during transport focuses on preventing the client from spreading infectious droplets.
B. The client should wear a gown during transport: Gowns are used to protect the nurse or caregiver from contact with infectious material, not primarily to prevent droplet spread from the client. Wearing a gown on the client does not effectively contain respiratory droplets during transport.
C. The nurse should wear a gown during transport: Gowns are indicated when contact with secretions is likely, but during transport, the main concern is droplet transmission from the client. Unless direct contact with secretions occurs, a gown is not required for the nurse.
D. The client should wear a mask during transport: Having the client wear a surgical mask helps contain respiratory droplets and prevents transmission to others in hallways or waiting areas. This is the most effective safety measure when transporting a patient on droplet precautions outside their room.
Correct Answer is C
Explanation
A. Apply petroleum jelly to the client's nares: Petroleum jelly is used to prevent nasal dryness from oxygen therapy, but it does not address hypoxia or aspiration risk. It is not a priority intervention in the care of a client with aspiration pneumonia.
B. Maintain the client in a supine position: Keeping the client supine increases the risk of further aspiration and can worsen hypoxia. Elevating the head of the bed is recommended to reduce aspiration risk and promote oxygenation.
C. Initiate fall precautions: Hypoxia can cause dizziness, confusion, or weakness, increasing the client’s risk for falls. Implementing fall precautions ensures safety while addressing potential complications of decreased oxygenation.
D. Implement contact precautions: Aspiration pneumonia is not typically transmitted via direct contact; standard precautions are usually sufficient. Contact precautions are not required unless there is a known multidrug-resistant organism present.
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