The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Notify the healthcare provider of the rebound tenderness.

Obtain a prescription to catheterize the client's bladder.

Offer to administer a laxative prescribed for PRN use.

Instruct the client in distraction and relaxation techniques.

Answer and Explanation

The Correct Answer is A

A) Notify the healthcare provider of the rebound tenderness:
Rebound tenderness, also known as Blumberg's sign, is a clinical sign that suggests peritoneal irritation, which can be indicative of underlying pathology such as peritonitis. Reporting rebound tenderness to the healthcare provider is crucial for further evaluation and management of the client's condition.

B) Obtain a prescription to catheterize the client's bladder:
While urinary retention can present with lower abdominal discomfort, the scenario described does not specifically suggest urinary retention. Catheterization should be considered based on additional assessments and indications related to urinary symptoms, not solely based on the client's report of pain upon release of abdominal pressure.

C) Offer to administer a laxative prescribed for PRN use:
Administering a laxative would not be appropriate based solely on the client's report of pain upon release of abdominal pressure. Laxatives are indicated for constipation, which may cause abdominal discomfort, but they would not address rebound tenderness or the underlying cause of the client's pain.

D) Instruct the client in distraction and relaxation techniques:
While distraction and relaxation techniques can be helpful for managing pain, they would not address the underlying cause of rebound tenderness. Reporting rebound tenderness to the healthcare provider is necessary for further evaluation and appropriate management.

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Correct Answer is D

Explanation

A) Face is flushed and diaphoretic:
While flushing and diaphoresis can indicate fever, anxiety, or other conditions, they do not typically require immediate intervention unless associated with other severe symptoms.

B) Eyelids are matted and crusted:
Matted and crusted eyelids may indicate an eye infection, such as conjunctivitis, which requires treatment but not immediate emergency intervention.

C) Cornea are jaundiced:
Jaundiced corneas (scleral icterus) suggest elevated bilirubin levels and possible liver dysfunction. This finding requires prompt evaluation but is not typically an emergency requiring immediate intervention.

D) Oral mucosa is cyanotic:
Cyanosis of the oral mucosa indicates a lack of oxygen in the blood and is a sign of hypoxemia or respiratory distress. This is a critical finding that requires immediate intervention to address potential life-threatening respiratory or cardiovascular issues.

A. Continue with the remainder of the client's physical assessment. B. Report the client's abnormal lung sounds to the healthcare provider. C. Ask the client to cough and then auscultate at the site again. D. Measure the client's oxygen saturation with a pulse oximeter.

Correct Answer is A

Explanation

A) Continue with the remainder of the client's physical assessment:
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, there is no immediate concern or need for further action related to this finding. The nurse should continue with the remainder of the client's physical assessment.

B) Report the client's abnormal lung sounds to the healthcare provider:
Vesicular breath sounds are considered normal lung sounds and do not warrant reporting as abnormal. Reporting this finding to the healthcare provider would not be appropriate and may lead to unnecessary concern or intervention.

C) Ask the client to cough and then auscultate at the site again:
Coughing would not be necessary in response to hearing vesicular breath sounds, as these are normal lung sounds. Repeating the auscultation may not provide additional information beyond confirming the presence of normal breath sounds.

D) Measure the client's oxygen saturation with a pulse oximeter:
Measuring oxygen saturation with a pulse oximeter is not indicated in response to hearing vesicular breath sounds. These breath sounds are normal and do not necessarily indicate a problem with oxygenation. Therefore, measuring oxygen saturation would not be the appropriate action in this situation.

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The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

Correct Answer is D

Explanation

While auscultating a client's breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

Correct Answer is A

Explanation

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