The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Implement an intervention.

Perform an assessment

Develop a nursing diagnosis.

Evaluate an outcome.

Answer and Explanation

The Correct Answer is D

A) Implement an intervention: Implementing an intervention is part of the nursing process, but in this context, administering an antipyretic is already an action that has been taken. The next step after implementing an intervention is to assess the outcome of that intervention.
B) Perform an assessment: Performing an assessment is crucial for gathering initial data and identifying problems. However, after administering an antipyretic, the next logical step is to evaluate the effectiveness of that intervention, not to perform an initial assessment.
C) Develop a nursing diagnosis: Developing a nursing diagnosis is part of the process used to identify patient problems based on the assessment data. Since the antipyretic has already been administered, the focus should now be on evaluating the effectiveness of this action rather than creating a new diagnosis.
D) Evaluate an outcome: Evaluating an outcome is the appropriate next step after administering an intervention like an antipyretic. The nurse should assess whether the medication has effectively reduced the fever, improved the client's condition, or resulted in any changes in vital signs. This step helps determine if the intervention was successful and guides further care planning.

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Correct Answer is C

Explanation

A. Glenohumeral joint: The glenohumeral joint is the shoulder joint. Pain with chewing is unlikely to be related to issues with the shoulder joint, as this joint is not involved in the chewing process.

B. Sternoclavicular joint: The sternoclavicular joint is where the clavicle meets the sternum. Problems here might affect shoulder and chest movement, but they would not typically cause pain specifically related to chewing.
C. Temporomandibular joint (TMJ): The TMJ is directly involved in the movement of the jaw, which is essential for chewing. Chronic pain during chewing often indicates a problem with the TMJ, such as TMJ disorder, which can cause pain, clicking, and other issues when moving the jaw.
D. Acromioclavicular joint: The acromioclavicular joint is located at the top of the shoulder where the clavicle meets the acromion of the scapula. This joint primarily affects shoulder movement, not chewing.

A. Sigmoid colon B. Appendix C. Right Fallopian Tube D. Ascending Colon E. Right kidney F. Right side of the prostate

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

Explanation

A) Sigmoid colon: The sigmoid colon is located in the Left Lower Quadrant (LLQ) of the abdomen. Therefore, a bulging area in the Right Lower Quadrant (RLQ) would not be associated with the sigmoid colon.
B) Appendix: The appendix is located in the Right Lower Quadrant and is a common site for abdominal masses, especially in cases of appendicitis. A bulging area in the RLQ could very well be related to issues with the appendix.
C) Right Fallopian Tube: The right fallopian tube is located in the RLQ of the abdomen. Conditions affecting the fallopian tube, such as an ectopic pregnancy or tubo-ovarian abscess, could cause a bulging area in this quadrant.
D) Ascending Colon: The ascending colon is also situated in the RLQ. A mass or bulge in this area could be related to conditions affecting the ascending colon, such as colonic obstruction or tumors.
E) Right kidney: The right kidney is located in the upper abdominal area and is more likely to cause tenderness or discomfort in the upper quadrants rather than a bulging mass in the RLQ.
F) Right side of the prostate: The prostate gland is located in the pelvic area, specifically in the male pelvis, and would not typically be associated with a bulging mass in the RLQ of a female patient.

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The nurse obtains vital signs on a newly admitted client: temperature 101.1 F (38.4 C), heart rate 101 bpm, BP 88/56 mm Hg. 02 Saturation 94% on room air. The nurse administers an antipyretic. What will be the next step of the nursing process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse assesses a client who reports chronic pain with chewing. The nurse should assess which body area to investigate the client's problem further?

Correct Answer is C

Explanation

During an abdominal examination, the nurse palpates a bulging area in the Right Lower Quadrant of a female patient. The nurse suspects that this mass could be associated with which of the following organs? (Select all that apply.)

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

Explanation

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