The client reports mid-abdominal pain rated as 7 on a scale of 1 to 10. The client states, "I haven't had a bowel movement in 4 days and have vomited once or twice.”. Which of the following should the nurse do first?
Assist the client to ambulate to promote bowel movement.
Encourage oral intake to prevent dehydration.
Administer prescribed anti-emetics.
Notify the provider for further evaluation.
The Correct Answer is D
Choice A rationale
Ambulation can stimulate peristalsis and promote bowel movements. However, ambulation is not the priority when the client reports severe abdominal pain rated 7/10 and vomiting. These symptoms could indicate a potential obstruction or other complications, and further evaluation is essential before initiating physical activity to avoid exacerbating the condition.
Choice B rationale
Encouraging oral intake is important to prevent dehydration, particularly if the client has been vomiting. However, this is not the first intervention, as assessing the underlying cause of the symptoms takes precedence. Increasing oral intake without addressing potential gastrointestinal obstruction may worsen the client's condition.
Choice C rationale
Administering antiemetics can provide symptom relief for nausea and vomiting. However, this intervention addresses a symptom rather than identifying the underlying cause of the client's abdominal pain and vomiting. Further evaluation by a provider is necessary before symptomatic management.
Choice D rationale
Notifying the provider allows for further evaluation and timely diagnosis of the cause of the abdominal pain and vomiting, which could indicate serious conditions like bowel obstruction or ischemia. Prompt medical evaluation is essential to determine the appropriate intervention and ensure the client's safety.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Palm oil is high in saturated fats, which increase LDL cholesterol levels and promote atherosclerosis progression, making it unsuitable for lowering fat and cholesterol.
Choice B rationale
Increasing consumption of 2% milk elevates intake of saturated fats, which can raise LDL cholesterol levels, negating dietary goals for atherosclerosis management.
Choice C rationale
Limiting meat portions to 3 ounces per meal controls saturated fat intake, reducing LDL cholesterol levels. It aligns with dietary recommendations for managing atherosclerosis.
Choice D rationale
Baked goods containing trans fats increase LDL cholesterol while decreasing HDL cholesterol levels, worsening atherosclerosis risk and contradicting dietary teaching. .
Correct Answer is A
Explanation
Choice A rationale
The client wearing a mask during transport helps minimize the risk of transmitting infectious droplets to others. It is the most effective precaution to uphold droplet isolation protocols and ensure safe transport in healthcare settings.
Choice B rationale
The nurse wearing a mask is standard PPE practice, but it does not address the primary goal of preventing the client from spreading infectious droplets during transportation. The client must be the primary focus of this preventive measure.
Choice C rationale
Wearing a gown is unnecessary for droplet precautions during transport. Droplet isolation measures primarily target respiratory secretions, and gowns are not effective for minimizing respiratory droplet dissemination.
Choice D rationale
Similar to Choice C, the nurse wearing a gown is not a droplet precaution strategy related to transportation. The focus remains on respiratory measures, specifically masking the client.
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