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 A

Explanation

A. Supporting the client in her personal decision respects her autonomy and right to make decisions about her own healthcare.
B. Referring the client to a counselor can be appropriate, but the primary response should be to support the client's decision.
C. Encouraging the client not to give up may not be appropriate if the client has made a well- considered decision to refuse further treatment.
D. Suggesting that the client talk with a breast cancer survivor may provide emotional support but should not be used as a means to persuade the client to undergo further treatment if she has made an informed decision to refuse.

A. Purulent B. Serous C. Sanguineous D. Hyperemia

Correct Answer is C

Explanation

A) Purulent drainage is indicative of pus, which is associated with infection and is typically thick and yellow, green, or brown.
B) Serous drainage is clear, thin, and watery, and is generally considered normal in the early stages of healing.
C) Sanguineous drainage, which is the correct answer, refers to drainage that contains or is mixed with blood, making it appear blood-tinged, and is expected in a fresh incision or one that is healing by secondary intention.
D) Hyperemia is not a type of drainage but a term that describes increased blood flow to an area of the body, resulting in redness. Therefore, the nurse should document the finding as sanguineous, which accurately describes blood-tinged drainage.

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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

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