24. A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps.
(Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen.
Listen to the abdominal arteries using the bell of a stethoscope.
Provide adequate lighting to inspect the abdomen.
Percuss all four quadrants of the abdomen to measure sound quality.
Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the
The Correct Answer is C,B,D,E,A
Choice A rationale:
Checking for areas of tenderness helps to identify any inflammation, infection, or injury in the abdominal cavity.
Choice B rationale:
Listening to the abdominal arteries helps to detect any bruits or abnormal sounds that may indicate vascular problems.
Choice C rationale:
Providing adequate lighting allows the nurse to inspect the abdomen for any abnormalities, such as distension, scars, or lesions.
Choice D rationale:
Percussing the abdomen helps to assess the size and density of the organs, as well as to detect any fluid or gas accumulation.
Choice E rationale:
Locating the liver and spleen borders helps to determine if they are enlarged or displaced.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Nighttime urinary incontinence can occur in older adults but is not a universal finding.
Choice B rationale:
Decreased sense of balance is a common age-related change in older adults and can contribute to an increased risk of falls.
Choice C rationale:
Older adults may have a decreased, rather than heightened, sense of pain due to various factors.
Choice D rationale:
Increased nighttime sleeping is not a typical finding in older adults and can vary among individuals.
Correct Answer is D
Explanation
Choice A rationale:
Hyperextending the client's back is not necessary and may cause discomfort or harm. Proper positioning is essential for the client's comfort and safety.
Choice B rationale:
Encouraging the client to try to defecate for an extended period may lead to unnecessary strain and discomfort. It's important to promote optimal conditions for toileting without excessive strain.
Choice C rationale:
Keeping the bed flat while the client is on the fracture pan is a correct action. Maintaining the bed's flat position facilitates proper use of the fracture pan and enhances the client's comfort.
Choice D rationale:
Placing the shallow end of the fracture pan under the client's buttocks is the correct way to position the pan for effective use. Proper use of the fracture pan is essential for its intended function in clients with immobility or limited mobility due to a cast.
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