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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. 2+ Pitting Edema:This refers to moderate pitting edema where the indentation is approximately 4 mm and disappears within 10-15 seconds.

B. 3+ Pitting Edema:This refers to moderately severe pitting edema where the indentation is approximately 6 mm and may last longer than 1 minute but does not remain for as long as 4 minutes.

C. 1+ Non-Pitting Edema:This grade refers to mild pitting edema with a 2 mm indentation that quickly disappears within a few seconds.

D. 4+ Pitting Edema:4+ pitting edema is characterized by a very deep pit (approximately 8 mm) that may last 2-5 minutes or more. This matches the scenario where the pit is 8 mm deep and remains for 4 minutes.

A. Air pads wrap around your arms and are connected to a vacuum which improves blood flow. B. These are elastic stockings that apply pressure to the legs and increase the velocity of blood flow. C. SCDs are only worn during amputation to provide support and prevent pooling of blood in the legs. D. The device fills with air that applies intermittent or sequential pressure to the legs to enhance blood flow and venous return.

Correct Answer is D

Explanation

The correct answer is choice D. The nurse would explain to the patient that SCDs work by filling with air and applying intermittent or sequential pressure to the legs to enhance blood flow and venous return. This can help prevent blood clots, such as DVT, from forming in the legs. SCDs are often used for patients who are immobile, such as those who have undergone surgery or who are hospitalized for a medical condition. The device is comfortable to wear and can be adjusted to fit the patient's size and shape. The nurse would also explain the importance of wearing the device as prescribed, and how to properly use and care for it. By using SCDs as directed, the patient can significantly reduce their risk of developing a potentially life-threatening blood clot.

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Naxlex Comprehensive Predictor Exams

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?

Correct Answer is D

Explanation

A nurse is implementing interventions to prevent a patient from developing Deep Vein Thrombosis (DVT) in the legs by applying a pneumatic or sequential compression device (SCD's). Which explanation would the nurse give the patient in regards to how this device works?

Correct Answer is D

Explanation

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?

Upon responding to the client's call bell, the nurse discovers the client's abdominal wound has been eviscerated. Initial nursing management includes calling the healthcare provider and which other initial action?

The nurse performed an assessment on a patient's upper extremities. All findings were within normal limits. Which reflects the most accurate and complete terminology used when documenting these normal results?

A nurse is assessing the radial pulse of a patient. The nurse would describe the pulse as brisk and would document this finding as a +2. What is the nurse's documentation describing?

A nurse is caring for a client with a wound on the lower extremity. What findings would the nurse observe that would indicate a wound infection?

The nurse has assessed the client, analyzed the data, and identified constipation as a patient health problem. Which assessment cues would support constipation? Select all that apply.

A new nurse understands that documentation guidelines are important to ensure accuracy. The nurse would perform which of the following documentation guidelines? Select all that apply.