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After receiving a report on an inpatient acute care unit, which client should the nurse assess first?
- A. The client with bowel obstruction due to a volvulus who is experiencing abdominal rigidity
- B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds
- C. The client with an obstruction of the large intestine who is experiencing abdominal distention
- D. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid
Correct Answer: A
Rationale: The correct answer is A. Abdominal rigidity in a client with bowel obstruction due to a volvulus indicates possible complications and requires immediate assessment. Choice B is incorrect because although a paralytic ileus with absent bowel sounds is concerning, abdominal rigidity in a client with a volvulus takes priority. Choice C is incorrect as abdominal distention, though indicative of an obstruction, is not as urgent as the sign of abdominal rigidity. Choice D is incorrect as the drainage of greenish fluid from a nasogastric tube in a client with a small bowel obstruction, while concerning, does not present as immediate a threat as the abdominal rigidity in a client with a volvulus.
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A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?
- A. Find supplies to put a dressing on the client's wrists
- B. Take the client to a room for supervision by staff
- C. Call the healthcare provider to report the client's behavior
- D. Go find a staff member to stay in the room with the client
Correct Answer: B
Rationale: In this situation, the nurse's priority is to ensure the safety and supervision of the client. Moving the client to a room for direct supervision by staff is crucial to prevent further harm and provide immediate support. While cleaning and assessing the client's wrists are important, ensuring ongoing supervision is vital in this scenario. Calling the healthcare provider to report the behavior may be necessary but is not the immediate action required. Finding supplies to dress the client's wrists is important but not as urgent as ensuring constant supervision by staff.
A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client's urine specific gravity is 1.035. What action should the nurse implement?
- A. Encourage popsicles and fluids of choice
- B. Evaluate postural blood pressure measurements
- C. Obtain a specimen for urinalysis
- D. Assess bowel sounds in all quadrants
Correct Answer: A
Rationale: Encouraging fluids helps address dehydration and potentially high urine specific gravity, which is often related to inadequate fluid intake. In this scenario, the client may be at risk of dehydration due to the appendectomy and the high urine specific gravity. Encouraging popsicles and fluids of choice can help increase fluid intake and improve hydration status. The other options are not the priority at this time. Postural blood pressure measurements may be relevant for assessing fluid status but are not the immediate action needed. Obtaining a specimen for urinalysis and assessing bowel sounds are not the priority actions based on the client's condition.
An older male resident of a long-term care facility has been scratching his legs for the past 2 days. Which intervention should the nurse implement?
- A. Explain the importance of bathing or showering daily
- B. Encourage fluid intake of at least 2,000 ml daily
- C. Keep the legs covered as much as possible
- D. Apply emollient to the affected area at least twice daily
Correct Answer: D
Rationale: The correct intervention for the nurse to implement in this scenario is to apply emollient to the affected area at least twice daily. This is because applying emollients helps address dry skin, which is a common cause of itching in older adults. Explaining the importance of bathing or showering daily (Choice A) may be helpful for general hygiene but may not specifically address the itching. Encouraging fluid intake (Choice B) and keeping the legs covered (Choice C) are not directly related to addressing the itching caused by dry skin.
What nursing intervention is most important to implement after a client has completed a myelogram?
- A. Lie-sit-stand blood pressure measurement
- B. Abdominal assessment for distention and bowel sounds
- C. Neurovascular assessment of lower extremities
- D. Assessment of skin temperature and turgor
Correct Answer: C
Rationale: The correct answer is C: Neurovascular assessment of the lower extremities. After a myelogram, it is crucial to monitor the neurovascular status to detect any signs of complications such as impaired circulation or nerve damage. This assessment helps in identifying early signs of vascular compromise or neurological deficits. Choices A, B, and D are not the priority after a myelogram. Lie-sit-stand blood pressure measurement is not directly related to post-myelogram care. Abdominal assessment and skin assessment are important but not the priority immediately after this procedure.
After a client with leukemia undergoes a bone marrow biopsy and is found to have thrombocytopenia, which nursing assessment is most important following the procedure?
- A. Observe the aspiration site
- B. Assess body temperature
- C. Monitor skin elasticity
- D. Measure urinary output
Correct Answer: A
Rationale: The correct answer is to observe the aspiration site. Thrombocytopenia, characterized by a low platelet count, increases the risk of bleeding. Therefore, monitoring the biopsy site for bleeding or hematoma is crucial to ensure early detection and intervention. Assessing body temperature (choice B) is not directly related to the increased bleeding risk associated with thrombocytopenia. Monitoring skin elasticity (choice C) and measuring urinary output (choice D) are important assessments but are not the priority in this situation where bleeding risk needs immediate attention.