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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should use the abbreviation “BRP” for bathroom privileges.
This is a commonly accepted abbreviation in the medical field and is used to indicate that a client has permission to use the bathroom.
Choice A is not the correct answer because “SC” is not a commonly accepted abbreviation for subcutaneous.
Instead, “SQ” or “SubQ” are more commonly used.
Choice B is not the correct answer because “SS” is not a commonly accepted abbreviation for sliding scale.
Instead, “Sliding Scale” should be written out in full to avoid confusion.
Choice D is not the correct answer because “OJ” is not a commonly accepted medical abbreviation for orange juice.
Instead, “orange juice” should be written out in full to avoid confusion.
Correct Answer is D
Explanation
This is important to prevent urine from flowing back into the bladder, which can cause infection 1.
Choice A is incorrect because the catheter should be secured to the outer side of the thigh, not taped to the lower abdomen 2.
Choice B is incorrect because attaching the drainage bag to the side rails of the bed can cause it to be above the level of the bladder.
Choice C is incorrect because it is important to empty the drainage bag regularly, not just when it is three-quarters full.
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