Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Palpate the abdomen.
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. Auscultate bowel sounds.
Auscultating bowel sounds is the priority to assess for signs of bowel obstruction or ileus, which can contribute to the client's symptoms.
C. Offer pain medication.
Offering pain medication can be addressed after the initial assessment and determination of the cause of the symptoms.
D. Administer an antibiotic.
Administering an antibiotic is premature before a diagnosis is confirmed. The priority is to assess and gather information first.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Fundamentals Proctored Exam 6. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is assessing a client's lower extremities and notes 6 mm pitting edema. Which of the following is appropriate documentation of this assessment finding?
A. 1+
1+ pitting edema is mild, with a slight indentation.
B. 4+
4+ pitting edema is severe, with a deep indentation that lasts a long time.
C. 3+
3+ pitting edema is moderate, with a deeper indentation that takes some time to rebound.
D. 2+
2+ pitting edema is moderate, with a slight indentation that rebounds fairly quickly.
Full Explanation
A. 1+ pitting edema is mild, with a slight indentation.
B. 4+ pitting edema is severe, with a deep indentation that lasts a long time.
C. 3+ pitting edema is moderate, with a deeper indentation that takes some time to rebound.
D. 2+ pitting edema is moderate, with a slight indentation that rebounds fairly quickly.
A nurse is preparing to insert an indwelling urinary catheter. Which of the following instructions should the nurse give the client to help ease the passage of the catheter through the urinary meatus?
A. "Raise your head off the pillow."
Raising the head off the pillow is not relevant to easing the passage of the catheter through the urinary meatus.
B. "Bear down."
Bearing down can help relax the pelvic floor muscles, making it easier to insert the catheter through the urinary meatus.
C. "Hold your breath."
Holding the breath is not typically instructed during catheter insertion and may not aid in the ease of the procedure.
D. "Perform Kegel exercises."
Performing Kegel exercises involves contracting pelvic floor muscles, which is not the desired action when inserting a urinary catheter.
Full Explanation
A. Raising the head off the pillow is not relevant to easing the passage of the catheter through the urinary meatus.
B. Bearing down can help relax the pelvic floor muscles, making it easier to insert the catheter through the urinary meatus.
C. Holding the breath is not typically instructed during catheter insertion and may not aid in the ease of the procedure.
D. Performing Kegel exercises involves contracting pelvic floor muscles, which is not the desired action when inserting a urinary catheter.
A nurse is teaching a client who is to receive transcutaneous electrical nerve stimulation (TENS) for pain management. The nurse should inform the client that TENS relieves pain by
A. providing distraction from the pain.
TENS does not primarily work by providing distraction from pain.
B. eliciting a relaxation response.
While relaxation may be a secondary effect, the primary mechanism of TENS is not to elicit a relaxation response.
C. modulating the transmission of the pain impulse.
TENS works by modulating the transmission of the pain impulse, disrupting pain signals from reaching the brain.
D. promoting increased circulation to the painful area.
TENS does not primarily work by promoting increased circulation to the painful area.
Full Explanation
A. TENS does not primarily work by providing distraction from pain.
B. While relaxation may be a secondary effect, the primary mechanism of TENS is not to elicit a relaxation response.
C. TENS works by modulating the transmission of the pain impulse, disrupting pain signals from reaching the brain.
D. TENS does not primarily work by promoting increased circulation to the painful area.