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 D
Explanation
Choice A reason:
While diarrhea can be a symptom of peptic ulcer disease, it is not typically considered a priority over more severe symptoms.
Choice B reason:
Dyspepsia (indigestion) is a common symptom of peptic ulcer disease, but it is not the priority over more concerning symptoms.
Choice C reason:
Epigastric discomfort is a symptom of peptic ulcer disease, but it is not the priority over more severe symptoms like hematemesis.
Choice D reason:
Hematemesis (vomiting blood) is a serious and potentially life-threatening symptom of peptic ulcer disease. It is the top priority for assessment and intervention.
Correct Answer is B
Explanation
Choice A reason:
While assessing the client's level of consciousness is important, it is not the priority after an EGD procedure. Ensuring the client's airway and protective reflexes is more crucial.
Choice B reason:
This is the correct answer. After an EGD, the client may have residual effects from sedation. Assessing the gag reflex helps ensure that the client's airway is protected.
Choice C reason:
Nausea is a common side effect after an EGD, but it is not the priority assessment. Ensuring the client's airway and safety come first.
Choice D reason:
Assessing pain is important for the client's comfort, but it is not the priority assessment after an EGD. Ensuring the client's airway and protective reflexes is more crucial.
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