Which patient will the nurse see first?

A patient with severe pain and nausea who feels like he or she is about to vomit

A patient writhing and moaning from abdominal pain after abdominal surgery

A patient who received morphine and has a pulse of 62 beats/min, respirations 10 breaths/min, and blood pressure 118/60 mmHg

A patient lying very still in bed who reports no pain but is pale with warm, dry skin

Answer and Explanation

The Correct Answer is C

Choice A reason: Severe pain and nausea with impending vomiting are urgent, but respiratory depression from morphine (respirations 10 breaths/min) is life-threatening due to hypoxia risk. Vomiting can be managed with antiemetics after addressing opioid-induced respiratory compromise, making this patient less immediate.

Choice B reason: Post-surgical abdominal pain with writhing and moaning requires pain management, but it is not immediately life-threatening compared to morphine-induced respiratory depression. Addressing airway and breathing takes precedence, as pain can be treated after stabilizing vital signs, making this less urgent.

Choice C reason: The patient with respirations of 10 breaths/min after morphine is the priority, as opioid overdose can lead to respiratory arrest. Pulse (62 beats/min) and blood pressure (102/60 mmHg) suggest compromise, requiring immediate intervention (e.g., naloxone) to reverse hypoxia, making this the most critical patient.

Choice D reason: A pale, still patient with warm, dry skin but no pain may indicate shock, but no vital sign abnormalities are specified. Morphine-induced respiratory depression presents a more immediate, clear danger, as low respirations risk hypoxia, making this patient less urgent.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Positioning on the right side is incorrect; the left side (Sim’s position) allows better solution flow into the colon. Right-side positioning hinders distribution, making this incorrect for enema administration.

Choice B reason: Cold tap water can cause cramping or shock. Warm water (105–110°F) ensures comfort and safety, making cold water incorrect for a cleansing enema solution.

Choice C reason: Inserting tubing 4 inches is excessive; 2–3 inches is sufficient for adults to reach the rectum safely. Deeper insertion risks injury, making this incorrect for proper technique.

Choice D reason: Holding the container 12 inches above the anus ensures safe, controlled flow, preventing pressure-related discomfort or injury. This standard height is correct for effective enema administration.

A. Crush enteric-coated tablets before administration B. Mix all medications together before administration C. Flush the tube with 30 mL of water before and after administration D. Administer medications in liquid form only

Correct Answer is C

Explanation

Choice A reason: Crushing enteric-coated tablets destroys their protective layer, causing gastric irritation or premature drug release. This is contraindicated, making it an incorrect action for nasogastric administration.

Choice B reason: Mixing medications together risks incompatibility, clogging the tube or altering efficacy. Administering separately with flushing ensures safety, making this an incorrect and unsafe practice.

Choice C reason: Flushing the tube with 30 mL of water before and after administration clears the tube, ensuring patency and complete drug delivery. This standard practice prevents clogs, making it the correct action.

Choice D reason: While liquid medications are preferred, some drugs require crushing if safe. Flushing ensures delivery regardless of form, making liquid-only administration unnecessarily restrictive and incorrect.

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Which patient will the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning to administer medications to a client who has a nasogastric tube. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching a client about foods to avoid before having an occult blood test of the stool. Which of the following foods should the nurse instruct the client to avoid?

A nurse is reviewing the medical record of a client who has a new prescription for warfarin. Which of the following findings should the nurse identify as a contraindication for this medication?

A postoperative patient complains of pain at the surgical site incision. Which of the following would be the priority action for the nurse to take?

A nurse is assessing a client who has a chest tube in place. Which of the following findings should the nurse report to the provider immediately?

The nurse is assessing a patient in ankle restraints and finds the extremities are cool and pale, nail beds are cyanotic, and capillary refill is >5 seconds. Which action should the nurse take first?

The nurse is caring for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention would be most appropriate to promote sleep?

Which of these enema orders would should the nurse question?

A nurse is planning care for a client admitted with diarrhea. Which of the following interventions should be prioritized for this client?