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 C

Explanation

Choice A rationale

Rating pain on a scale from 0 to 10 assesses pain intensity rather than quality. Intensity quantifies the severity of pain but does not describe its characteristics, such as sharpness, dullness, or burning, which are essential for understanding the pain's nature and underlying etiology.

Choice B rationale

Asking about pain presence or absence identifies whether the client is experiencing pain but provides no information about its quality. This question is insufficient for determining pain characteristics, which require descriptive responses to guide appropriate intervention and diagnosis.

Choice C rationale

Asking the client what their pain feels like elicits a description of pain quality. Quality includes terms such as throbbing, sharp, or burning, which help identify the type of pain and its potential causes, differentiating between nociceptive, neuropathic, or referred pain.

Choice D rationale

Comparing current pain to previous pain assesses pain trends and patterns but does not address the quality of the pain. This question is more suited for evaluating treatment effectiveness over time rather than diagnosing the nature of the pain.

A. Remove the dressing and tape from the venipuncture site. B. Withdraw the catheter from the client's vein. C. Perform hand hygiene. D. Apply pressure to the venipuncture site with sterile gauze.

Correct Answer is C,A,B,D

Explanation

Choice Crationale

Hand hygiene prevents introducing pathogens during the procedure, reducing the risk of infection at the venipuncture site.

Choice Arationale

Removing the dressing and tape exposes the IV site for catheter removal. Proper technique minimizes tissue trauma and discomfort.

Choice Brationale

Withdrawing the catheter removes the IV device. It is performed gently to avoid complications like vein damage or retained fragments.

Choice D rationale

Applying pressure with sterile gauze prevents bleeding by promoting hemostasis at the venipuncture site.

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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 collecting data from a client about her current pain status.Which of the following Questions should the nurse ask to determine the quality of the client's pain?

Correct Answer is C

Explanation

A nurse is preparing to discontinue a client's intravenous infusion. Identify the sequence the nurse should follow to remove the IV catheter.

Correct Answer is C,A,B,D

Explanation

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