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?

Monitor urinary output

Obtain an electrocardiogram

Restrict activity to bed rest

Initiate NPO status

Answer and Explanation

The Correct Answer is D

A. Monitoring urinary output is important for assessing kidney function and hydration status, but it is not the immediate priority in this situation. The abrupt cessation of inhalation during palpation suggests acute abdominal pathology that requires immediate attention.
B. Obtaining an electrocardiogram (ECG) is necessary in cases of suspected cardiac issues, but the symptoms described are more indicative of an acute abdominal condition, such as peritonitis or cholecystitis, rather than a cardiac event.
C. Restricting activity to bed rest may help prevent further discomfort or complications, but it is not the most critical immediate action. The client’s acute symptoms suggest the need for more urgent interventions.
D. Initiating NPO (nothing by mouth) status is the most important action because the client may require surgical intervention or further diagnostic testing for an acute abdominal condition. NPO status is essential to prepare the client for potential surgery and to prevent further complications.

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Free Nursing Study Resources

Correct Answer is ["A","H","I"]

Explanation

Shoulder - unable to move the arm away from the body: Abduction
Rationale: Abduction refers to moving the arm away from the body. If the client is unable to perform this movement, it indicates a limitation in shoulder abduction.
Elbow - only able to straighten joint 20 degrees: Extension
Rationale: Extension involves straightening the joint. The client’s ability to only straighten the elbow 20 degrees suggests limited extension.
Wrist - able to bend wrist back: Extension
Rationale: Extension of the wrist refers to bending the wrist backward, away from the palm. If the client can perform this movement, it indicates functional wrist extension.

A. A minor variation B. Normal borborygmus sounds C. Possible renal artery stenosis D. Hyperactive bowel sounds

Correct Answer is C

Explanation

A. A minor variation would not typically produce a low-pitched blowing sound during auscultation. This sound is more concerning and usually suggests a vascular issue rather than a normal variation.
B. Normal borborygmus sounds are the typical gurgling or rumbling noises caused by the movement of gas and fluid in the intestines. They are not described as low-pitched blowing sounds and are heard more generally across the abdomen rather than specifically in the upper midline area.
C. A low-pitched blowing sound in the upper midline area could indicate possible renal artery stenosis, which is the narrowing of one or both renal arteries. This condition can cause turbulent blood flow, leading to an audible bruit during auscultation.
D. Hyperactive bowel sounds are usually high-pitched, frequent, and associated with increased peristalsis. They do not typically present as a low-pitched blowing sound, making this option incorrect.

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Joint	Type of range of motion
Shoulder - unable to move the arm away from the body	Flexion-a Adduction-a Abduction-a Extension-a
Elbow - only able to straighten joint 20 degrees	Flexion-b Adduction-b Abduction-b Extension-b
Wrist - able to bend wrist back	Flexion-c Adduction-c Abduction-c Extension-c

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

Correct Answer is ["A","H","I"]

Explanation

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Correct Answer is C

Explanation

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

Exhibits Heart sounds are loudest for Sl at the dropdown and for S2 at the dropdown

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

Which assessment finding supports the client statement, "My feet swell all the time?"

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

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.