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 A
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 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.
Correct Answer is A
Explanation
Choice A reason: Nasogastric suction removes gastric acid (HCl), reducing hydrogen ions, raising pH, and causing metabolic alkalosis, a common post-surgical complication here.
Choice B reason: Panic attacks cause respiratory alkalosis from hyperventilation, lowering CO2, not metabolic alkalosis, which involves base excess, unrelated to this ABG.
Choice C reason: ESRD typically causes metabolic acidosis from acid retention, not alkalosis, as kidneys fail to excrete hydrogen, opposing this patient’s ABG findings.
Choice D reason: Epidural catheters manage pain with analgesics, not affecting acid-base balance or causing metabolic alkalosis, irrelevant to the ABG shift observed.
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