A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)
Left upper quadrant
Right upper quadrant
Right lower quadrant
Left upper quadrant
The Correct Answer is C
Choice A reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice B reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice C reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Choice D reason:
McBurney's point is a point on the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the umbilicus
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Keeping the patient in a low Fowler's position may not directly address the management of the NG tube and dysphagia.
Choice B reason:
Connecting the tube to continuous wall suction when not in use is not a standard intervention for NG tube feeding.
Choice C reason:
This statement is correct. Confirming placement of the tube prior to each medication
administration is crucial to ensure safe and effective delivery of medications and nutrition.
Choice D reason:
Having the patient sip cool water, while a general recommendation for some patients, does not specifically address the care of the NG tube.
Correct Answer is D
Explanation
- A: This response minimizes the client's feelings and may make them feel unheard. It's important for healthcare providers to acknowledge a patient's feelings and provide reassurance in a more empathetic manner.
- B: This response delays addressing the client's concerns and may increase his anxiety. Consent is important, but it should not be a barrier to discussing care and addressing concerns.
- C: This response is factual but does not address the client's immediate concern about pain. It's crucial to address the client's fears directly rather than deflecting to the procedure's necessity.
- D: This response directly addresses the client's concern about pain by informing him of the sedative, which is a common practice to reduce discomfort during a colonoscopy. It provides reassurance and factual information about the procedure's process.
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