A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr.

Which of the following actions should the nurse take first?

Offer pain medication.

Auscultate bowel sounds.

Palpate the abdomen.

Administer an antiemetic.

Answer and Explanation

The Correct Answer is B

The nurse should first auscultate the client’s bowel sounds.
This will provide important information about the client’s gastrointestinal function and can help determine the cause of the client’s symptoms.
Choice A is wrong because while offering pain medication may provide temporary relief, it does not address the underlying cause of the client’s symptoms.
Choice C is wrong because palpating the abdomen before auscultating bowel sounds can alter the bowel sounds and make it more difficult to accurately assess the client’s condition.
Choice D is wrong because administering an antiemetic may provide temporary relief from nausea and vomiting, but it does not address the underlying cause of the client’s symptoms.

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Correct Answer is C

Explanation

The first two actions the nurse should take are to review the client’s medical history and assess for symptoms.
This can help determine if further testing or treatment is necessary.

Choice A is wrong because the test results are negative, so initiating treatment for TB is not necessary.
Choice B is wrong because repeating the tests may not provide any additional information.
Choice D is wrong because educating the client about TB prevention and management may not be necessary if the client does not have TB.

A. The client's skin on the lower back is intact without redness. B. The client states that he is able to concentrate while reading. C. The client's vital signs are within the expected reference range. D. The client is laughing at a television show.

Correct Answer is A

Explanation

This indicates that the compress has been effective in relieving lower back pain and has not caused any skin irritation or damage.
Choice B is wrong because the ability to concentrate while reading is not directly related to the effectiveness of a warm, moist compress for relieving lower back pain.
Choice C is wrong because vital signs being within the expected reference range does not necessarily indicate that the compress has been effective in relieving lower back pain.
Choice D is wrong because laughing at a television show does not necessarily indicate that the compress has been effective in relieving lower back pain.

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A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client. Exhibits What are the first two actions the nurse should take?

Correct Answer is C

Explanation

When caring for a client who is receiving a warm, moist compress to relieve lower back pain, which of the following findings should indicate to the nurse that the compress has been effective?

Correct Answer is A

Explanation

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A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr.

Which of the following actions should the nurse take first?