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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Removing the dressing and tape while wearing sterile gloves is not an appropriate action. Sterile gloves are reserved for direct contact with a sterile field or wound. Contaminating sterile gloves during this step defeats their purpose in infection control.

Choice B rationale

Assessing the wound structure using sterile gauze is not a recognized infection control measure. While sterile gauze minimizes the risk of introducing pathogens, its use does not directly ensure overall infection control during dressing changes.

Choice C rationale

Disposing of dressings in the designated waste container is a standard practice for safe disposal. However, it is not sufficient alone to ensure infection control. Proper hand hygiene and aseptic techniques are equally important.

Choice D rationale

Washing hands thoroughly before touching the sterile field eliminates transient microorganisms that could compromise sterility. It is a critical step in maintaining infection control during dressing changes and hygiene measures. .

A. Instruct the client to remain flat in bed for 4 to 6 hours after the procedure. B. Prepare the client for a chest x-ray following the procedure. C. Set up the equipment using clean technique. D. Insert an indwelling urinary catheter and record the client's output.

Correct Answer is B

Explanation

Choice A rationale

Remaining flat in bed post-thoracentesis can impair respiratory function by reducing lung expansion. Proper positioning facilitates pleural fluid clearance and reduces dyspnea risk. Elevating the head enhances ventilation and drainage, improving post-procedural recovery and minimizing complications.

Choice B rationale

Post-procedure chest x-rays confirm successful fluid removal and monitor for complications like pneumothorax, common after pleural interventions. Imaging validates lung re-expansion and ensures pleural integrity, critical for addressing new or worsening respiratory distress symptoms.

Choice C rationale

Aseptic, not clean technique, minimizes infection risk during thoracentesis. Sterile precautions protect against bacterial introduction into the pleural space, which can cause empyema, a severe complication. All materials and the procedure field should meet sterile standards.

Choice D rationale

Urinary catheter insertion is unrelated to thoracentesis and poses unnecessary infection risks. The procedure focuses on resolving pleural fluid issues, and urinary monitoring is not standard unless clinically indicated for other medical concerns. .

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for dressing change and hygiene measures.Which of the following actions should the nurse take to ensure proper infection control?

Correct Answer is D

Explanation

A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress.Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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