Practice Question
A nurse in an emergency department is assessing a client who reports right lower quadrant pain, nausea, and vomiting for the past 48 hr. Which of the following actions should the nurse take first?
Answer Choices:
Correct Answer:
Auscultate bowel sounds.
Rationale:
🎧 In an acute abdomen, follow the correct sequence: inspect → auscultate → percuss → palpate so you don’t alter bowel sounds before assessing them.
🎧 Palpation can stimulate peristalsis, worsen pain, and confound findings (e.g., guarding/rebound), so it should come after auscultation.
🎧 Brief assessment should precede meds; analgesics/antiemetics are important, but giving them first can obscure clinical cues and baseline data.
🎧 With RLQ pain, nausea, vomiting (possible appendicitis), auscultation provides objective baseline information (e.g., hypoactive/absent sounds or obstructive “tinkling”) to guide the rest of the exam.
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This question is from ☑️ ATI-RN Fundamentals-Miami Regional University which contains 37 questions.
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From Exam
☑️ ATI-RN Fundamentals-Miami Regional University
37 Questions
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- Category: RN Nursing Exam(s)
- Subcategory: ATI Exam(s)
- Domain: RN ATI Fundamentals of Nursing
- Answer Choices: 4