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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["20"]
Explanation
To calculate the amount of carbamazepine oral suspension needed for each dose, divide the total daily dose by the concentration of the suspension and then by the number of doses per day.
- 800 mg / 20 mg/mL / 2 = 20 mL
The nurse should administer 20 mL of carbamazepine oral suspension with each dose.
Correct Answer is A
Explanation
A. The client's belief that his needs will be met through education reflects intrinsic motivation, which is likely to enhance the client's commitment to learning and self-care.
B. Seeking family approval may be a motivator, but it is an external factor, and intrinsic motivation is generally more effective for sustained behavior change.
C. While the nurse explaining the need for education is important, the client's personal belief and understanding of the value of education are key for motivation.
D. The nurse's empathy is essential for building rapport, but the client's belief in the benefits of education is more directly related to motivation.
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