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Which of the following clients should be seen first?

A patient hospitalized with acute pancreatitis and is sitting in a high Fowler’s position leaning over the bedside table.

A patient who had bariatric surgery and is reporting shoulder pain and heart racing.

A patient who is one day post-op after an intestinal resection and colostomy, and has no effluent in the bag.

A patient with cirrhosis and is reporting loose stools.

Answer and Explanation

The Correct Answer is B

Choice A rationale
A patient with acute pancreatitis sitting in a high Fowler’s position leaning over the bedside table may be experiencing discomfort, but it is not an immediate life-threatening situation.
Choice B rationale
A patient who had bariatric surgery and is reporting shoulder pain and heart racing could be experiencing complications such as a pulmonary embolism, which is a life-threatening condition. This patient should be seen first.
Choice C rationale
A patient who is one-day post-op after an intestinal resection and colostomy and has no effluent in the bag may need further assessment, but it is not an immediate life-threatening situation.
Choice D rationale
A patient with cirrhosis reporting loose stools may be uncomfortable, but it is not an immediate life-threatening situation.

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Correct Answer is C

Explanation

Choice A rationale
At the time the client takes a proton-pump inhibitor. Sucralfate and proton pump inhibitors should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
Choice B rationale
At the time the client takes an antacid. Sucralfate and antacids should not be taken at the same time. Sucralfate can interfere with the absorption of other medications.
Choice C rationale
One hour before breakfast and the evening meal. This is the correct answer. Sucralfate is most effective when taken on an empty stomach. Taking it one hour before meals allows it to form a protective coating on the ulcer before food is introduced into the stomach.
Choice D rationale
Thirty minutes after breakfast and the evening meal. Sucralfate should not be taken immediately after meals. It is most effective when taken on an empty stomach.

A. Increase the feeding to 35ml/hr. B. Decrease the feeding to 10ml/hr. C. Continue the feeding as ordered. D. Hold the feeding and notify the doctor.

Correct Answer is C

Explanation

A gastric residual volume of 10ml is not considered high. The client is receiving 60ml/hr of feeding, which is within normal limits. Therefore, the nurse should continue the feeding as ordered.

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Which of the following clients should be seen first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily. When should the nurse plan to administer the medication?

Correct Answer is C

Explanation

The nurse is assessing tube feeding residual amounts and finds 10ml of residual. The client is receiving 60ml/hr of feeding. What action should the nurse take?

Correct Answer is C

Explanation

Which of the following conditions could potentially lead to a gastrointestinal bleed? (Select all that apply.)

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The nurse is reviewing orders for a patient in anaphylactic shock. Which medications should the nurse plan to administer first?

A client with a spinal cord injury is at risk for experiencing autonomic dysreflexia. Which of the following manifestations should the nurse carefully monitor the client for?

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A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. How many mL of fluids can the client have over the next 20 hr if the client had a total fluid intake of 300 mL during the first 4 hr of the shift?