A client reports a new onset of abdominal discomfort to the nurse. What is the most appropriate intervention at this time?
Administer standing PRN pain medication
Reposition the client to the prone position
Perform an assessment of the abdomen
Request an order for an abdominal x-ray
The Correct Answer is C
A. Administer standing PRN pain medication: Administering pain medication before performing an assessment may mask critical clinical signs, such as tenderness, guarding, or rebound, which are essential for identifying the underlying cause of abdominal discomfort. Pain control is important but should follow an accurate assessment.
B. Reposition the client to the prone position: While repositioning may offer temporary comfort, it does not provide diagnostic information or address the potential underlying cause of abdominal discomfort. Prone positioning is not a standard intervention for new-onset abdominal pain and could even obscure signs during assessment.
C. Perform an assessment of the abdomen: The priority action is a thorough abdominal assessment, including inspection, auscultation, palpation, and evaluation of associated symptoms. This provides vital information about bowel sounds, distention, tenderness, or rigidity, which guides further interventions and ensures patient safety.
D. Request an order for an abdominal x-ray: Diagnostic imaging may be warranted depending on assessment findings, but requesting tests before performing a clinical assessment is premature. The initial evaluation determines the need, urgency, and type of diagnostic studies, ensuring efficient and appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Hepatic: While liver function can influence fluid and electrolyte balance, hyponatremia primarily affects neuronal function rather than hepatic status. Hepatic assessment is not the priority in acute low sodium levels unless there is a known underlying liver disorder contributing to the imbalance.
B. Neurological: The nervous system is most sensitive to changes in serum sodium because sodium regulates extracellular fluid osmolarity and neuronal excitability. Severe hyponatremia (120 mEq/L) can lead to cerebral edema, confusion, seizures, lethargy, and potentially coma, making neurological monitoring the priority for patient safety.
C. Gastrointestinal: Hyponatremia can contribute to nausea, vomiting, or anorexia, but these symptoms are secondary manifestations. While GI assessment is important, it is not as urgent as monitoring for potentially life-threatening neurological complications.
D. Respiratory: Sodium imbalances do not directly impair respiratory function. Respiratory assessment is important in overall patient care, but hyponatremia at this level does not typically compromise ventilation unless severe neurological impairment affects respiratory drive.
Correct Answer is C
Explanation
A. Metabolic acidosis: Metabolic acidosis occurs when there is an excess of hydrogen ions or a loss of bicarbonate, as seen in conditions like diarrhea or renal failure. Nasogastric suction primarily removes gastric hydrochloric acid, which does not cause acidosis, this is not the expected imbalance.
B. Respiratory acidosis: Respiratory acidosis results from hypoventilation, leading to CO₂ retention and decreased pH. NG suction does not directly affect respiratory function or CO₂ levels, so this is unlikely.
C. Metabolic alkalosis: Prolonged nasogastric suction removes hydrochloric acid from the stomach. The loss of H⁺ ions leads to a rise in blood pH, creating a metabolic alkalosis. This is a classic complication of continuous or prolonged NG suction, especially over several days.
D. Respiratory alkalosis: Respiratory alkalosis is caused by hyperventilation, resulting in decreased CO₂ levels. NG suction does not induce hyperventilation or CO₂ loss, this imbalance is not expected.
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