A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

Gurgling bowel sounds every 10 seconds

Centrally located umbilical protrusion

Abdominal distention during breathing

Rebound tenderness with palpation

Answer and Explanation

The Correct Answer is D

Choice A reason: Gurgling bowel sounds every 10 seconds are considered normal, as normoactive bowel sounds range from 5 to 30 sounds per minute. This finding indicates regular gastrointestinal activity and is not typically a cause for concern.

Choice B reason: A centrally located umbilical protrusion can be a normal finding, especially if it has been present since birth and is not associated with any other symptoms. However, if new or associated with pain or other symptoms, it could indicate a hernia or other pathology.

Choice C reason: Abdominal distention during breathing can be a normal finding, as the abdomen may distend slightly during deep breathing due to the movement of the diaphragm. However, if the distention is pronounced or associated with other symptoms, it may warrant further investigation.

Choice D reason: Rebound tenderness with palpation is a sign of peritoneal irritation and can be an indication of conditions such as appendicitis, which is a surgical emergency. This finding should be considered a priority as it may require immediate intervention.

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Correct Answer is C

Explanation

Choice A reason: Administering aspirin is one of the first interventions for a client experiencing acute angina because aspirin has antiplatelet properties that help prevent blood clots, which can reduce the risk of a heart attack.

Choice B reason: Measuring blood pressure is important but not the first action to take. It provides valuable information about the cardiovascular status of the client and can influence further treatment decisions.

Choice C reason: Administering nitroglycerin is a priority action for acute angina as it helps to dilate the coronary arteries and relieve chest pain. However, it is typically administered after aspirin unless contraindicated.

Choice D reason: Initiating IV access is an important step in the management of acute angina, as it allows for the administration of medications and fluids if needed. However, it is not the first action to take during an acute angina episode.

A. Move the client to a double room. B. Use a bed alarm. C. Encourage participation in activities that provide excessive stimulation. D. Use chemical restraints at bedtime.

Correct Answer is B

Explanation

Choice A reason: Moving the client to a double room may not be effective in preventing wandering and could potentially lead to confusion or agitation if the client is not comfortable with the roommate or the new environment.

Choice B reason: Using a bed alarm is a non-invasive way to alert staff if the client attempts to leave the bed. This can help prevent wandering and ensure the safety of the client without restricting their movement unnecessarily.

Choice C reason: Encouraging participation in activities that provide excessive stimulation is not recommended for clients with dementia, as it can lead to increased confusion, agitation, and potentially exacerbate wandering behaviors.

Choice D reason: The use of chemical restraints, such as sedative medications, should be a last resort and only used when necessary to ensure the safety of the client or others. It is important to use the least restrictive measures first and to always consider the ethical implications of using chemical restraints.

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A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has acute angina. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

Correct Answer is B

Explanation

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