A client comes to the emergency department complaining of abdominal cramping and severe persistent diarrhea. The client has recently traveled outside of the United States to an area that may be prone to water contamination. The physician has written several orders. Which assessment and diagnostic physician order would be the first priority for the nurse to complete based on the patient's symptoms?
Abdominal sounds and colonoscopy.
Bowel sounds and obtain a stool specimen.
Abdominal inspection and kidney, bowel, and ureter x-ray.
Bowel palpation and abdominal x-ray.
The Correct Answer is B
The correct answer is choice B: Bowel sounds and obtain a stool specimen.
When a client presents with abdominal cramping and persistent diarrhea, obtaining a stool specimen is the first priority to determine the cause of the diarrhea. The stool specimen can be sent to the laboratory for analysis to check for the presence of bacteria, viruses, or parasites. The nurse should also assess bowel sounds as part of the client's abdominal assessment to monitor for any changes in bowel motility. The other options listed are not the first priority in this situation and may be ordered after the cause of the diarrhea has been determined.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. When conducting a physical assessment of the extremities, the most appropriate assessment would be to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity. This comprehensive assessment can help to identify potential issues with circulation, strength, and skin integrity, and can also provide a baseline for ongoing assessments. Rebound tenderness in both the arms and legs, skin turgor, and moisture (choice B) are not typically assessed during a physical assessment of the extremities. Assessing the measurements in centimeters of each extremity, pulses, and varicosities (choice C) may be appropriate in certain situations, but it is not a comprehensive assessment of the extremities. Assessing pulses, strength, range of motion, percussion, odor, and edema (choice D) is also not a comprehensive assessment of the extremities and may not provide a complete picture of the client's condition. Therefore, the most appropriate assessment when conducting a physical assessment of the extremities is to assess pulses, capillary refill, strength, edema, skin, and compare with the other extremity.
Correct Answer is ["A","B","C","E"]
Explanation
A.Observe for signs and symptoms of respiratory distress.
B.Auscultate anterior and posterior lung fields.
C. Inspect the skin for pallor and cyanosis.
E. Observe rate, rhythm, and depth of respirations.
When assessing a client's oxygenation status, a nurse should observe for signs and symptoms of respiratory distress, such as dyspnea, wheezing, and use of accessory muscles. Auscultation of the anterior and posterior lung fields is important to identify any adventitious breath sounds such as crackles, wheezes or rhonchi that may indicate airway obstruction, fluid accumulation, or other respiratory abnormalities. Inspection of the skin is also important to detect pallor or cyanosis, which may indicate reduced oxygen levels in the blood. Lastly, observing the rate, rhythm, and depth of respirations can provide information on the adequacy of oxygen exchange in the lungs.
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