Difficulty: Medium
Average Score: 74%
Simulated
Passage / Scenario
Nurses' NotesVital Signs
Laboratory Results
Provider Prescriptions
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days." The client states, "I also have vomited once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
A nurse is assisting with the care of the client Complete the following sentence by using the list of options. The nurse should first plan to.... followed by.....
Correct answer
A,D
Rationale
The nurse should first ensure the nasogastric tube is correctly placed to address vomiting and obstruction, followed by requesting an antiemetic to manage nausea.