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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Giving the client water to drink might help produce more urine, but it does not address the immediate issue of potential bladder distention, which can cause discomfort and urinary retention.
B. Evaluating the client for bladder distention is the priority action. The symptoms of lower abdominal discomfort and difficulty urinating suggest possible urinary retention, which could be due to an enlarged prostate or other obstructive issues. Assessing for bladder distention will help determine if the bladder is full and if further interventions, such as catheterization, are needed.
C. Instructing the client to try urinating again may not be effective if the client is experiencing urinary retention, and it doesn't address the underlying issue.
D. Sending the few drops of urine for evaluation could provide some information but does not address the potential problem of bladder distention or retention.

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

Correct Answer is C

Explanation

A. Measuring blood pressure when lying and standing assesses for orthostatic hypotension, not orthopnea.
B. Observing for jugular vein distention can indicate fluid overload but is not specific to orthopnea.
C. Orthopnea is the discomfort or difficulty in breathing that occurs when lying flat. Asking the client how many pillows are used to sleep at night helps determine if they need to be propped up to breathe comfortably, which is a key indicator of orthopnea.
D. Auscultating breath sounds while supine can provide valuable information but does not directly assess for orthopnea.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample. After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

Correct Answer is B

Explanation

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

Correct Answer is C

Explanation

A male client arrives at the clinic for a follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

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

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor. How should the nurse expect the ear to appear when performing an otoscopic examination?

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

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