Which patient should the nurse assess first after receiving a change-of-shift report?
A patient with a scheduled physical therapy session in 1 hour.
A patient with a routine follow-up appointment for a non-urgent condition.
A patient with altered mental status and confusion.
A patient with moderate pleuritis and requesting pain medication.
The Correct Answer is C
A. While this patient is scheduled for a physical therapy session, it is not an urgent concern that would require immediate attention.
B. A routine follow-up appointment for a non-urgent condition can be managed at a later time and does not take priority over more acute concerns.
C. A patient with altered mental status and confusion should be assessed first. This could indicate a serious underlying issue such as infection, hypoxia, or a neurological condition. Altered mental status in any patient warrants immediate attention to prevent further complications.
D. Although the patient with pleuritis is in pain, moderate pleuritis is typically not an urgent condition, and pain management can be provided after more pressing concerns are addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encouraging coughing and deep breathing is important for promoting the clearance of respiratory secretions. However, while it aids in mobilizing secretions, it does not directly thin the mucus.
B. Frequent ambulation helps to improve overall lung function and prevent complications like pneumonia, but it does not specifically thin respiratory secretions.
C. Increasing fluid intake helps thin the respiratory secretions by providing hydration, making it easier for the body to expel mucus through coughing. Hydration is critical for reducing the viscosity of sputum, thus promoting its removal.
D. Regular use of the incentive spirometer helps prevent atelectasis and improve lung expansion but does not directly affect the thinning of respiratory secretions.
Correct Answer is C
Explanation
A. Total loss of gastric enzymes is not a primary cause of dumping syndrome. While gastric enzymes may be reduced following gastric surgery, the syndrome is primarily related to the way food moves through the digestive tract.
B. Excess secretion of digestive enzymes in the intestines does not directly cause dumping syndrome. Although enzyme levels can be affected by surgery, dumping syndrome is more about the timing and volume of food delivery to the intestines.
C. Rapid emptying of stomach contents into the small intestine is the primary cause of dumping syndrome. This occurs because the normal regulatory mechanisms of the stomach are bypassed or disrupted after gastric resection, leading to a quick shift of food into the small intestine, which causes symptoms like nausea, diarrhea, and dizziness.
D. Excess glycogen production by the liver is not related to dumping syndrome. This would be more relevant to conditions affecting glucose metabolism, not gastrointestinal emptying.
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