During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation.

Which prescription is most important for the nurse to implement?

Restrict activity to bed rest.

Monitor urinary output.

Initiate NPO status.

Obtain an electrocardiogram.

Answer and Explanation

The Correct Answer is C

Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.

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Correct Answer is C

Explanation

Choice A rationale
Tenderness upon palpation of the thoracic region is an abnormal finding and may indicate inflammation, infection, or other pathological conditions.
Choice B rationale
A thrill is a palpable vibration over the chest wall, often associated with turbulent blood flow due to cardiac abnormalities. It is not a normal finding in the thoracic region.
Choice C rationale
Non-tenderness upon palpation of the thoracic region is a normal finding, indicating the absence of inflammation, infection, or other abnormalities.
Choice D rationale
Crepitus is a crackling or popping sensation felt under the skin, often due to the presence of air in the subcutaneous tissue. It is not a normal finding and may indicate conditions such as pneumothorax or subcutaneous emphysema.

A. Observe for jugular vein distention while the client is flat in bed. B. Auscultate breath sounds while the client is supine. C. Measure the blood pressure when the client is lying and standing. D. Ask the client how many pillows are used to sleep on at night.

Correct Answer is D

Explanation

Choice D rationale
Orthopnea is a condition where individuals have difficulty breathing while lying flat and may need to sleep with multiple pillows or in a more upright position to alleviate symptoms.
Therefore, asking the client about the number of pillows used for sleep can provide valuable information about the presence and severity of orthopnea.
Choice A rationale
While jugular vein distention can indicate fluid overload or heart failure, it is not a direct assessment of orthopnea, which is the difficulty breathing while lying flat.
Choice B rationale
Auscultating breath sounds while the client is supine can provide information about lung function and the presence of abnormal breath sounds, but it does not specifically address orthopnea.
Choice C rationale
Measuring the blood pressure when the client is lying and standing assesses for orthostatic hypotension, which is a drop in blood pressure upon standing. While orthostatic hypotension can contribute to symptoms of dizziness or fainting upon assuming an upright position, it does not directly assess orthopnea.

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During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

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During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation.

Which prescription is most important for the nurse to implement?