A nurse is assessing a client who presents to the emergency department with reports of right lower quadrant pain, nausea, and vomiting for the past 2 days. Which of the following actions should the nurse take first?
Palpate the abdomen.
Auscultate bowel sounds.
Offer pain medication.
Administer an antibiotic.
The Correct Answer is B
A. Palpating the abdomen may exacerbate pain or cause discomfort, and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step.
B. Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C. Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D. Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.
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Related Questions
Correct Answer is C
Explanation
A. Getting up and walking with the physical therapy aide promotes early mobility and is a positive statement.
B. Doing leg exercises every hour while awake helps prevent complications such as deep vein thrombosis (DVT).
C. Leaving antiembolic stockings on during sleep helps prevent DVT, so the client's statement is incorrect.
D. Using a footstool while sitting in a chair promotes proper positioning and comfort.
Correct Answer is C
Explanation
A. Vest restraints are not appropriate for seizure precautions. Restraints are generally not recommended as the primary intervention for seizure management.
B. The use of tongue blades during a seizure is not recommended and could pose a risk of injury.
C. Oxygen setup is crucial for managing a client during and after a seizure to ensure proper oxygenation.
D. Neck brace is not necessary for seizure precautions and may pose a risk during a seizure episode.
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