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?

Nothing by mouth.

Electrocardiogram.

Monitor urinary output.

Complete bed rest.

Answer and Explanation

The Correct Answer is A

Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis). Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.

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Correct Answer is D

Explanation

Choice A Reason:
Having the client lay flat while listening to the anterior surface of the chest is incorrect because having the client lay flat may not be the most optimal position for auscultating lung sounds. While auscultation of the anterior surface of the chest is important, particularly for assessing the upper lobes of the lungs, having the client lay flat may not provide the best positioning for detecting all lung sounds, especially those located in the posterior lung fields.
Choice B Reason:
Using the bell of the stethoscope to listen to the lung fields over lower lobes is incorrect because using the bell of the stethoscope is more suitable for detecting low-frequency sounds such as heart murmurs or bruits. Adventitious lung sounds, such as crackles (rales) or wheezes, are typically high-pitched sounds that are best heard using the diaphragm of the stethoscope. Therefore, using the bell may not be the most effective technique for assessing adventitious lung sounds.
Choice C Reason:
Shaving all chest hair that may distort sounds heard through the diaphragm is incorrect because while removing chest hair may improve sound transmission for certain auscultatory findings, such as heart sounds, it is not specifically indicated for assessing adventitious lung sounds. Chest hair removal is not necessary for auscultation of lung sounds with the diaphragm of the stethoscope, as the sound transmission through chest hair is minimal and unlikely to significantly distort lung sounds.
Choice D Reason:
Pressing the stethoscope's diaphragm firmly on the skin over each lung field is correct because using the diaphragm of the stethoscope and pressing it firmly on the skin over each lung field ensures good contact with the chest wall, allowing for optimal transmission of lung sounds. Adventitious lung sounds, such as crackles or wheezes, are best heard using the diaphragm, particularly when it is applied firmly to the chest wall to minimize external noise and enhance sound transmission. Therefore, this technique is the most appropriate for assessing adventitious lung sounds during auscultation.

A. Jugular venous distension. B. Peripheral edema. C. Dyspnea. D. Intercostal retractions. E. Headaches.

Correct Answer is ["A","B","C"]

Explanation

Choice A Reason:
Jugular venous distension is correct. Jugular venous distension is a common sign of fluid overload and increased central venous pressure, which occur during exacerbations of heart failure. It indicates impaired cardiac function and elevated systemic venous pressure.
Choice B Reason:
Peripheral edema is correct. Peripheral edema, particularly in the lower extremities, is a classic manifestation of fluid retention and congestion in heart failure exacerbations. It results from increased capillary hydrostatic pressure and impaired fluid reabsorption by the kidneys.
Choice C Reason:
Dyspnea is correct. Dyspnea, or shortness of breath, is a hallmark symptom of heart failure exacerbations. It occurs due to pulmonary congestion resulting from fluid accumulation in the lungs, impairing gas exchange and leading to difficulty breathing.
Choice D Reason:
Intercostal retraction is not typically associated with exacerbations of heart failure. Intercostal retractions indicate increased work of breathing and respiratory distress, which may occur in conditions such as severe respiratory infections or asthma exacerbations, but are not specific to heart failure exacerbations.
Choice E Reason:
Headaches are not typically associated with exacerbations of heart failure. Headaches can have various causes, including tension, migraines, or sinus congestion, but they are not commonly observed as a direct manifestation of heart failure exacerbations.

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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

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

Correct Answer is D

Explanation

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Correct Answer is ["A","B","C"]

Explanation

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