A nurse is caring for a 46-year-old male client in the emergency department who is experiencing difficulty breathing that has worsened over the last 24 hours.

Exhibits

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Answer and Explanation

The Correct Answer is []

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Correct Answer is B

Explanation

Choice A rationale
Asking the client to describe any other related symptoms is important for a comprehensive assessment but does not objectively confirm the presence of fever.
Choice B rationale
Placing the dorsum of the hand on the client’s forehead is a quick and practical method to assess for fever. It provides an initial subjective assessment of the client’s temperature before taking an accurate measurement with a thermometer.
Choice C rationale
Using both hands to hold and palpate the client’s hands may help assess for other symptoms such as clamminess or coldness but does not objectively confirm the presence of fever.
Choice D rationale
Lightly pinching a fold of skin over the client’s sternum assesses skin turgor and hydration status but does not objectively confirm the presence of fever.

A. Offer to administer a laxative prescribed for PRN use. B. Obtain a prescription to catheterize the client’s bladder. C. Notify the healthcare provider of the rebound tenderness. D. Instruct the client in distraction and relaxation techniques.

Correct Answer is C

Explanation

Choice A rationale
Offering to administer a laxative prescribed for PRN use is not appropriate in this situation, as the presence of rebound tenderness suggests a more serious underlying condition, such as appendicitis.
Choice B rationale
Obtaining a prescription to catheterize the client’s bladder is not indicated, as the symptoms are related to abdominal pain and rebound tenderness, not urinary retention.
Choice C rationale
Notifying the healthcare provider of the rebound tenderness is the appropriate action, as this finding could indicate a serious condition such as appendicitis. Prompt medical evaluation and intervention are necessary.
Choice D rationale
Instructing the client in distraction and relaxation techniques may help manage pain, but it does not address the underlying cause of the rebound tenderness. Immediate medical evaluation is required.

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Naxlex Comprehensive Predictor Exams

To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?

Correct Answer is B

Explanation

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

Correct Answer is C

Explanation

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