The nurse is receiving hand-off report. Which of the following clients would the nurse assess first?
A client with an intestinal obstruction whose nasogastric tube has drained 150 mL in 8 hours
A client with ascites who has a respiratory rate of 26 and oxygen saturation level of 90%
A client with acute pancreatitis who has decreased breath sounds with increased crackles
A client with stable esophageal varices and a blood pressure of 92/45
The Correct Answer is C
Choice A reason: 150 mL NG drainage in 8 hours is low for obstruction, suggesting stability; it’s less urgent than respiratory compromise in other clients.
Choice B reason: Respiratory rate 26 and 90% saturation indicate distress in ascites, but crackles suggest fluid overload, less acute than pancreatitis’s pulmonary risk.
Choice C reason: Decreased breath sounds and crackles in pancreatitis signal pleural effusion or ARDS, a life-threatening complication, prioritizing immediate respiratory assessment.
Choice D reason: BP 92/45 with stable varices is concerning but not acutely unstable without bleeding signs, less critical than respiratory failure in pancreatitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Levothyroxine takes weeks to normalize metabolism in hypothyroidism as T4 converts to T3 gradually, so immediate symptom relief isn’t accurate or expected.
Choice B reason: Levothyroxine supplements, not decreases, thyroxine in hypothyroidism. Decreasing overproduction applies to hyperthyroidism treatments like antithyroid drugs, not this condition.
Choice C reason: Hypothyroidism requires lifelong levothyroxine since the thyroid can’t produce hormone. Stopping when symptoms resolve risks recurrence, making this advice incorrect.
Choice D reason: Excess levothyroxine mimics hyperthyroidism, causing tremors, nervousness, and insomnia from overstimulated metabolism, correctly indicating a need for dose adjustment.
Correct Answer is B
Explanation
Choice A reason: Bradycardia occurs in hypothyroidism; Graves’ disease, hyperthyroidism, speeds metabolism, causing tachycardia, not slowed heart rate, during exacerbation.
Choice B reason: Heat intolerance in Graves’ disease results from excess thyroid hormone accelerating metabolism, raising body temperature, a hallmark of hyperthyroidism flares.
Choice C reason: Weight gain aligns with hypothyroidism’s slowed metabolism; Graves’ causes weight loss from increased calorie burning, opposite to this finding.
Choice D reason: Lethargy reflects hypothyroidism’s energy drop; Graves’ exacerbation increases metabolism, leading to restlessness or fatigue from overactivity, not lethargy.
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