The nurse is caring for a client who has not had a bowel movement in four days. What should the nurse do first?
Assessing bowel sounds helps determine whether peristalsis is present or if an obstruction may be developing.
A client newly diagnosed with diabetes asks why regular foot checks are necessary. Which response is best?
Diabetes can reduce sensation, increasing the risk of unnoticed injuries and infection.
A client prescribed an antibiotic reports developing itching and a rash. What is the nurseu2019s first action?
Itching and rash may indicate an allergic reaction. Stopping the antibiotic prevents progression.
A diabetic client reports numbness in both feet. What should the nurse do first?
Numbness indicates diabetic neuropathy and requires provider notification for further management.
The nurse notes a client with heart failure is coughing up pink, frothy sputum. What should the nurse do first?
Pink, frothy sputum is a classic sign of pulmonary edema. Checking oxygen saturation helps determine the severity of respiratory compromise.
The nurse notes that a client with pneumonia has a respiratory rate of 32 breaths per minute. What is the nurseu2019s priority?
A high respiratory rate indicates respiratory distress. Assessing lung sounds helps determine the extent of airway involvement.
A client taking a new cholesterol medication reports muscle pain. What should the nurse do first?
Muscle pain can indicate myopathy, a serious side effect of some cholesterol medications. Reporting it ensures early evaluation.
A client with a urinary catheter has cloudy, foul-smelling urine. What should the nurse do first?
Cloudy, foul-smelling urine may indicate infection. Reporting it ensures timely evaluation.
A postoperative client reports severe pain unrelieved by medication. What should the nurse do first?
Unrelieved pain may indicate complications such as bleeding or infection. Assessing the surgical site helps determine the cause.