A nurse is assessing a client who presents to the emergency department with reports of right lower quadrant pain, nausea, and vomiting for the past 2 days. Which of the following actions should the nurse take first?

Palpate the abdomen.

Auscultate bowel sounds.

Offer pain medication.

Administer an antibiotic.

Answer and Explanation

The Correct Answer is B

A.   Palpating the abdomen may exacerbate pain or cause discomfort, and it is not the first action in the assessment of a client with suspected appendicitis. Auscultating bowel sounds is a more appropriate initial step.
B.   Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C.   Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D.   Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.

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Correct Answer is D

Explanation

A. Tilted head forward is not necessary during inhaler use. The client should maintain an upright position.
B. Shaking the inhaler before use is correct to ensure proper dispersion of the medication.
C. Rinsing the mouth out before using the inhaler is not necessary for proper technique.
D. Waiting 10 seconds between puffs allows for optimal delivery of the medication to the airways.

A. Unsteady gait B. Report of short-term memory loss C. Hearing loss D. Report of frequent constipation

Correct Answer is A

Explanation

A. An unsteady gait increases the risk of falls, which can lead to serious injuries in older adults.

A. Ensuring safety and preventing falls is a priority.

B. Short-term memory loss is common in older adults, but it may not pose an immediate risk to safety.
C. Hearing loss, while important, may not be an immediate safety concern unless it significantly impacts the individual's ability to communicate or hear warnings.
D. Frequent constipation is a common concern in older adults but may not pose an immediate threat to safety. Falls prevention takes precedence in this scenario.

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A nurse is assessing a client who presents to the emergency department with reports of right lower quadrant pain, nausea, and vomiting for the past 2 days. Which of the following actions should the nurse take first?

Nursing Test Bank

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