A 67-year-old male client is admitted to a health care facility with abdominal pain and suspected abdominal aneurysm. The client relates a 10-year history of high blood pressure and history of arterial insufficiency diagnosed 7 years ago. Following auscultation of the abdomen for bowel sounds, what other assessment should the nurse perform at this time?

Observe for evidence of increased abdominal girth.

Palpate the abdomen for masses, pulsations.

Auscultate for a friction rub.

Listen with the bell of the stethoscope for vascular sounds.

Answer and Explanation

The Correct Answer is D

A. Observing for increased abdominal girth is important for conditions such as ascites but is not the priority assessment for a suspected abdominal aneurysm.
B. Palpating the abdomen for masses or pulsations is contraindicated in suspected abdominal aneurysms, as it may cause rupture.
C. Auscultating for a friction rub is used for liver or spleen inflammation and is not relevant in this case.
D. Listening with the bell of the stethoscope for vascular sounds is correct because an abdominal aneurysm may produce a bruit, which can be heard over the affected artery. This assessment helps confirm the presence of turbulent blood flow, a key sign of an aneurysm.

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Correct Answer is A

Explanation

A. Having the client cough, then listening again is correct. Sometimes wheezing can be due to mucus or secretions in the airways, and coughing can help clear them. If wheezing persists, further assessment and interventions may be needed.
B. Teaching pursed-lip breathing is beneficial for chronic obstructive pulmonary disease (COPD) patients but is not the first action in an acute assessment.
C. Checking O₂ saturation and applying O₂ is important but not the first step. Oxygen therapy is not indicated unless there is evidence of hypoxia.
D. Administering a nebulizer treatment should only be done if wheezing persists and is causing respiratory distress, but the nurse should first confirm that the wheezing is not due to mucus plugging, which may resolve with coughing.

A. A 3-year-old child with fever, rash, and sore throat. B. A 45-year-old man with chest pain and diaphoresis for 1 hour. C. A 14-year-old girl who is crying because she thinks she is pregnant. D. A 20-year-old man with a 3-inch shallow laceration on his leg.

Correct Answer is B

Explanation

A. A 3-year-old with fever, rash, and sore throat should be evaluated promptly, but these symptoms do not necessarily indicate an immediate life-threatening emergency.
B. A 45-year-old man with chest pain and diaphoresis for 1 hour is the priority because these are classic symptoms of acute coronary syndrome (ACS) or myocardial infarction (MI). Immediate emergency assessment and intervention are required.
C. A 14-year-old girl crying about a possible pregnancy needs emotional support and counseling but does not require immediate emergency intervention.
D. A 20-year-old man with a 3-inch shallow laceration on his leg needs wound care, but his condition is not life-threatening and does not require emergency assessment.

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Naxlex Comprehensive Predictor Exams

A nurse is auscultating a client's lungs during the initial assessment of the patient in the emergency room. The nurse hears wheezes on expiration in the lower posterior lobes bilaterally. Which of the following actions should the nurse do first?

Correct Answer is A

Explanation

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

Correct Answer is B

Explanation

The nurse is caring for a client who has been diagnosed with colon cancer. When planning the client's care, the nurse should be aware of what function of the colon?

Which of the following statements indicate that the student nurse understands the importance of documenting the initial assessment data?

What is the primary purpose of a nursing health assessment?

A 45-year-old client with dark skin tone comes to the clinic complaining of fatigue, thirst, and frequent urination. During the examination, the nurse notices areas of hyperpigmentation around the neck and in the axillae. What is the priority intervention by the nurse?

A 40-year-old client is seen at the clinic with a headache and blurred vision that comes and goes. The client reports a pain of a 6 on a scale from 0–10. What question should the nurse ask to obtain more information about the pattern of the pain?

The nurse is performing an assessment of a client admitted to the emergency department with respiratory distress. The nurse should carefully inspect which part of the body to identify central cyanosis?

A nurse is admitting a new client to the subacute medical unit and is completing a comprehensive assessment. The nurse is appropriately applying standard precautions by performing which action below?