A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

Right upper quadrant

Left upper quadrant

Left lower quadrant

Right lower quadrant

Answer and Explanation

The Correct Answer is C

A. Pressing in the right upper quadrant is not appropriate for a referred rebound tenderness test, which is used to assess peritoneal irritation, commonly from appendicitis.
B. Pressing in the left upper quadrant is not useful in diagnosing appendicitis or conditions that cause referred pain to the right lower quadrant.
C. Pressing in the left lower quadrant is correct when performing Rovsing’s sign, a test for referred rebound tenderness. If the client experiences pain in the right lower quadrant when the left lower quadrant is pressed, it suggests peritoneal irritation, often due to appendicitis.
D. Pressing in the right lower quadrant would directly elicit tenderness in appendicitis but does not test for referred rebound tenderness.

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Correct Answer is A

Explanation

A. Having the client cough, then listening again is correct. Sometimes wheezing can be due to mucus or secretions in the airways, and coughing can help clear them. If wheezing persists, further assessment and interventions may be needed.
B. Teaching pursed-lip breathing is beneficial for chronic obstructive pulmonary disease (COPD) patients but is not the first action in an acute assessment.
C. Checking O₂ saturation and applying O₂ is important but not the first step. Oxygen therapy is not indicated unless there is evidence of hypoxia.
D. Administering a nebulizer treatment should only be done if wheezing persists and is causing respiratory distress, but the nurse should first confirm that the wheezing is not due to mucus plugging, which may resolve with coughing.

A. The client's infection is no longer localized and has become systemic. B. The client likely has a cardiac health problem, not a respiratory health problem. C. The client's signs and symptoms are related to hypothermia rather than infection. D. The client's normothermic temperature does not rule out the presence of an infection.

Correct Answer is D

Explanation

A. Systemic infection can cause fever, but older adults often present with atypical signs, including a lack of fever, rather than the classic response.
B. The presence of a productive cough, abnormal breath sounds, and shortness of breath suggests a respiratory infection rather than a cardiac issue.
C. While older adults may be more susceptible to hypothermia, the client’s symptoms align with infection rather than hypothermia.
D. "The client's normothermic temperature does not rule out the presence of an infection" is correct because older adults may have a blunted febrile response to infection due to age-related changes in thermoregulation. An absence of fever does not exclude infection in elderly patients.

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A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is D

Explanation

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