A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr.
Which of the following actions should the nurse take first?
Offer pain medication.
Auscultate bowel sounds.
Palpate the abdomen.
Administer an antiemetic.
The Correct Answer is B
The nurse should first auscultate the client’s bowel sounds.
This will provide important information about the client’s gastrointestinal function and can help determine the cause of the client’s symptoms.
Choice A is wrong because while offering pain medication may provide temporary relief, it does not address the underlying cause of the client’s symptoms.
Choice C is wrong because palpating the abdomen before auscultating bowel sounds can alter the bowel sounds and make it more difficult to accurately assess the client’s condition.
Choice D is wrong because administering an antiemetic may provide temporary relief from nausea and vomiting, but it does not address the underlying cause of the client’s symptoms.
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Correct Answer is D
Explanation
This is because before providing the client with information about insulin self-administration and other resources, it is important to first determine whether the client can afford the insulin administration supplies.
This will help to ensure that the client has access to the necessary supplies for managing their diabetes mellitus.
Choice A is wrong because making a copy of the medication reconciliation form for the client is not the first action that should be taken.
While it is important to provide the client with a copy of their medication reconciliation form, this should be done after determining whether the client can afford the insulin administration supplies.
Choice B is wrong because obtaining printed information about insulin self-administration is not the first action that should be taken.
While it is important to provide the client with information about insulin self-administration, this should be done after determining whether the client can afford the insulin administration supplies.
Choice C is wrong because providing the client with the contact number for a diabetes education specialist is not the first action that should be taken.
While it is important to provide the client with resources for diabetes education, this should be done after determining whether the client can afford insulin administration supplies.
Correct Answer is C
Explanation
The first two actions the nurse should take are to review the client’s medical history and assess for symptoms.
This can help determine if further testing or treatment is necessary.
Choice A is wrong because the test results are negative, so initiating treatment for TB is not necessary.
Choice B is wrong because repeating the tests may not provide any additional information.
Choice D is wrong because educating the client about TB prevention and management may not be necessary if the client does not have TB.
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