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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. A client with diminished vision ambulating in well-lit areas may be at risk for falling but is not at the greatest risk among the options provided.
B. A client who received a diuretic 30 min ago may experience orthostatic hypotension, which can increase the risk of falling, but it is not the highest risk.
C. A client who requires assistance with ambulation is generally at a lower risk than a client who has recently experienced a tonic-clonic seizure.
D. A client who had a tonic-clonic seizure 2 hr ago is at the greatest risk for falling due to potential residual weakness, disorientation, or postictal state following the seizure.

A. Test for the presence of the client's gag reflex. B. Lubricate the lips with petroleum jelly. C. Place the client in the supine position. D. Use a firm toothbrush for tooth and gum care.

Correct Answer is B

Explanation

A. Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B. Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.

C. Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D. Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients. Which of the following clients is at the greatest risk for falling?

Correct Answer is D

Explanation

A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Correct Answer is B

Explanation

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