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.

Answer and Explanation

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.

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Correct Answer is ["C","E"]

Explanation

A. Taking all drugs one hour before mealtime is not typically recommended for patients recovering from upper G.I. bleeding. Medications like proton pump inhibitors or antacids may be prescribed to reduce stomach acid, but timing varies. The patient should follow the specific instructions given by the healthcare provider regarding medication administration, especially in the context of G.I. issues.
B. Limiting alcohol intake is important for general health, but after an episode of upper G.I. bleeding, alcohol should be avoided or minimized entirely. Alcohol can irritate the stomach lining and increase the risk of further bleeding. The healthcare provider may recommend complete abstinence from alcohol during recovery.
C. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can cause irritation of the stomach lining and increase the risk of bleeding, so they should be avoided after an episode of upper G.I. bleeding. This is crucial for preventing recurrence of bleeding.
D. Taking aspirin with milk or bread does not negate its potential for irritation or bleeding risk. Patients recovering from upper G.I. bleeding should avoid aspirin entirely unless specifically directed otherwise by the healthcare provider.
E. Only taking drugs prescribed by the healthcare provider is essential. Over-the-counter medications, especially NSAIDs, should be avoided unless directed by a healthcare provider, as they can exacerbate the risk of further G.I. bleeding.

A. Apply petroleum jelly to the nares as needed to soothe mucous membranes. B. Attach a humidifier bottle to the base of the flow meter. C. Remove the nasal cannula while the client eats. D. Secure the oxygen tubing to the bed sheet near the client's head.

Correct Answer is B

Explanation

A. Petroleum jelly should not be used on the nares with oxygen therapy, as it is flammable and could pose a fire hazard. Non-petroleum-based lubricants should be used if needed.
B. A humidifier should be attached to the flow meter when delivering oxygen at higher flow rates (such as 6 L/min) to prevent dryness and irritation of the mucous membranes in the nose and throat.
C. The nasal cannula should generally be kept on during meals to ensure continued oxygen therapy, unless it is uncomfortable or the client has other medical needs.
D. The oxygen tubing should be secured to the client’s body or clothing in a way that does not restrict movement or cause injury, but securing it to the bed sheet could lead to a potential tripping hazard or interfere with mobility.

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Which patient should the nurse assess first after receiving a change-of-shift report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a teaching plan for a patient being discharged after an acute episode of upper G.I. bleeding. What important information should the teaching plan include? Select all that apply.

Correct Answer is ["C","E"]

Explanation

A nurse is caring for a client who has pneumonia and a prescription for oxygen therapy at 6 L/min via nasal cannula. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A patient with right lower-lobe pneumonia has been treated with IV antibiotics for 3 days. Which assessment data obtained by the nurse indicates that the treatment is effective?

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A patient is being treated for bleeding esophageal varices with balloon tamponade. Which of the following nursing actions will the nurse include in the plan of care?

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