A client with acute abdominal pain, persistent nausea, and projectile vomiting is admitted to the hospital for observation. Acetaminophen is administered as prescribed for an oral temperature of 103°F (39.4°C) and an IV infusion of normal saline is initiated at 250 ml/hour. Which assessment finding should the nurse report to the healthcare provider immediately?

Petechial haemorrhage under client's eyes.

Right lower abdomen rebound tenderness.

Severe headache with photosensitivity.

Dark green coloured emesis.

Answer and Explanation

The Correct Answer is B

Choice A reason: Petechial haemorrhage under the client's eyes can be a sign of various conditions, including increased intrathoracic pressure from vomiting. However, it is not the most urgent finding in this scenario. The nurse should focus on the finding that indicates a potential life-threatening condition.

Choice B reason: Right lower abdomen rebound tenderness is a sign of peritonitis, which can be caused by appendicitis or other serious abdominal conditions. This is an urgent finding that requires immediate medical attention, as it indicates inflammation of the peritoneum and potential risk of perforation or severe infection.

Choice C reason: Severe headache with photosensitivity can be associated with conditions such as meningitis or migraines. While concerning, it does not take precedence over the abdominal signs that indicate a potentially life-threatening condition like peritonitis.

Choice D reason: Dark green coloured emesis can be indicative of bile or upper gastrointestinal content, which might be seen in conditions such as intestinal obstruction or vomiting. However, it is not as urgent as the finding of rebound tenderness, which suggests an acute and severe abdominal condition that needs immediate intervention.

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Correct Answer is D

Explanation

Choice A reason: Pacing the client's care to provide periods of rest is important for managing fatigue and preventing overexertion. However, it is not the first action the nurse should take in this situation. Monitoring vital signs is crucial to assess the client's current condition and detect any immediate complications.

Choice B reason: Making arrangements for radioactive iodine therapy is a treatment option for hyperthyroidism. However, this is not the first action the nurse should take. The nurse needs to assess the client's condition and stabilize any immediate issues before considering long-term treatment options.

Choice C reason: Administering a beta-adrenergic blocking agent can help manage symptoms such as a racing heartbeat and nervousness. While this may be part of the treatment plan, it is not the first action the nurse should take. Monitoring vital signs is essential to determine the appropriate interventions.

Choice D reason: Monitoring the client's vital signs frequently is the first action the nurse should take. This helps assess the client's current condition, detect any immediate complications, and guide further interventions. It is crucial to ensure the client's stability before implementing other care measures.

A. The client gained 5 pounds (2.27 kg) over the last six months. B. A family member recently contracted viral influenza. C. There is a known family history of lung disease. D. The client cleaned house with cleaning supplies.

Correct Answer is D

Explanation

Choice A reason: Gaining weight over six months can affect overall health and potentially exacerbate asthma symptoms by increasing the workload on the respiratory system. However, it is not an immediate trigger for asthma exacerbation.

Choice B reason: A family member contracting viral influenza poses a risk of the client catching the virus, which can exacerbate asthma. However, it is not a direct trigger of the asthma exacerbation unless the client actually contracts the virus.

Choice C reason: A family history of lung disease can indicate a genetic predisposition to respiratory issues, but it is not an immediate trigger for an asthma exacerbation.

Choice D reason: Cleaning with household supplies is a significant trigger for asthma exacerbation. Many cleaning products contain strong chemicals that can irritate the airways and provoke an asthma attack. This is the most immediate and direct cause of the client's asthma complications among the given options.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client admitted to the unit for possible hyperthyroidism. The client describes weakness, nervousness, a racing heartbeat, and recent weight loss of 15 pounds (6.8 kg). Which action should the nurse implement first?

Correct Answer is D

Explanation

An adult client has been admitted to the hospital with asthma exacerbation. Which trigger should the nurse identify as being the most significant cause of this client's asthma complications?

Correct Answer is D

Explanation

The nurse is evaluating a client's understanding of diet teaching about the DASH (Dietary Approaches to Stop Hypertension) eating plan. Which behaviour indicates that the client is adhering to the eating plan?

A client with a history of diabetes mellitus and hypertension received new medication prescriptions three days ago. Today the client returns to the clinic reporting a severe headache and blurred vision. Which intervention should the nurse implement first?

The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?

A 26-year-old client is admitted to the hospital for treatment of a simple goitre, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?

A client reports a 2-day history of fever, vomiting, and diarrhea. The healthcare provider prescribes serum electrolyte levels to be obtained. Which laboratory results should the nurse expect?

A client with type 1 diabetes mellitus calls the home care nurse and reports taking a morning dose of 70/30 insulin before realizing they have a stomach virus and are now unable to eat breakfast due to nausea. Which initial instruction should the nurse provide the client?

A client is newly diagnosed with type 2 diabetes mellitus. The nurse is educating the client about self-monitoring blood glucose (SMBG) and haemoglobin A1C. Which statement by the client indicates teaching has been effective?