A young adult female presents at the emergency department (ED) with acute lower abdominal pain. Which assessment finding is most important for the nurse to report to the healthcare provider (HCP)?
Last menstrual period was 7 weeks ago.
Reports white, curdy vaginal discharge.
History of irritable bowel syndrome (IBS).
Pain scale rating of a 9 on a 0 to 10 scale.
The Correct Answer is A
Rationale:
A. Last menstrual period was 7 weeks ago: A missed period in a young adult female with acute lower abdominal pain raises concern for possible ectopic pregnancy, which is a life-threatening emergency if unrecognized. Early reporting to the healthcare provider is critical for timely evaluation and intervention.
B. Reports white, curdy vaginal discharge: This finding is suggestive of a yeast infection, which is uncomfortable but not immediately life-threatening. It requires assessment but is not the highest priority.
C. History of irritable bowel syndrome (IBS): IBS may cause recurrent abdominal pain, but it is a chronic condition. While relevant to the client’s history, it is less urgent than a potential ectopic pregnancy.
D. Pain scale rating of a 9 on a 0 to 10 scale: Severe pain is important to address and manage, but pain alone is nonspecific. The underlying cause, such as ectopic pregnancy, must be identified first, making the missed period more urgent to report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Ask the UAP to position the client so the oral medications can be administered: The client is showing signs of acute clinical deterioration, including weakness, pallor, and diaphoresis. Administering oral medications without assessing airway, circulation, and neurologic status is unsafe. Medication administration is not the priority in an unstable client.
B. Explain to the UAP that changes in a client's condition should be reported immediately: While education of the UAP is important, it does not address the client’s immediate physiologic instability. Teaching can occur after the client has been assessed and stabilized. Immediate clinical evaluation takes precedence.
C. Advise the UAP to stop providing care so the nurse can assess the client's condition: The nurse must first assume care and perform a rapid assessment to identify potential life-threatening conditions. Pallor and diaphoresis may indicate shock, hypoglycemia, or acute cardiac compromise. Direct assessment is the priority nursing responsibility.
D. Determine why the UAP did not notify the nurse of the change in the client's condition: Investigating communication breakdowns is appropriate after the client’s condition has been evaluated and managed. Focusing on accountability before assessment delays critical care. Patient safety requires immediate clinical action.
Correct Answer is ["200"]
Explanation
Calculation:
- Identify the total volume and infusion time
Total Volume: 100 mL
Infusion Time: 30 minutes (0.5 hour)
- Calculate the infusion rate
Infusion Rate (mL/hr) = Total Volume ÷ Time (hr)
Infusion Rate = 100 ÷ 0.5
Infusion Rate = 200 mL/hr
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