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 B

Explanation

A. Ciprofloxacin 200 mg IV q12h x 7 days is a clear and acceptable prescription.
B. "Dx" is an unaccepted abbreviation; it is not appropriate for documentation and may lead to confusion.
C. "Hourly 180" is unclear and may need clarification; it could refer to an hourly measurement or a specific order, but it lacks clarity.
D. Acetaminophen 1000 mg PO QD is a clear and acceptable prescription.

A. Eat a light carbohydrate snack before bedtime. B. Take a 30 min daily nap. C. Exercise 1 hr before bedtime. D. Drink a cup of hot cocoa before bedtime.

Correct Answer is A

Explanation

A. Eating a light carbohydrate snack before bedtime can promote sleep by providing a small increase in insulin, which facilitates the entry of tryptophan into the brain, promoting the production of serotonin and melatonin.

B. Taking a 30-minute daily nap, especially close to bedtime, may interfere with nighttime sleep.
C. Exercising 1 hour before bedtime can be stimulating and may disrupt sleep patterns.
D. Drinking a cup of hot cocoa before bedtime may not be recommended as it contains caffeine, which can interfere with sleep.

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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

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