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 D
Explanation
Choice A rationale:
A blood glucose level of 110 mg/dL is within the normal range and is an expected finding.
Choice B rationale:
A weight gain of 0.91 kg (2 lb) in 2 days could be expected in a client receiving enteral feeding due to fluid intake. However, it's important to monitor for signs of fluid overload.
Choice C rationale:
Diarrhea one time in a 24-hour period can occur in some clients but should be monitored for any patterns or changes.
Choice D rationale:
A gastric residual of 300 mL at the end of the shift is higher than expected and may indicate delayed gastric emptying or intolerance to enteral feeding. This finding should be reported.
Correct Answer is C
Explanation
Choice A rationale:
Recapping the needle before disposal is not recommended due to the risk of needlestick injuries.
Choice B rationale:
Placing the needle on the bedside table poses a safety risk and is not an appropriate action.
Choice C rationale:
Discarding the needle in a puncture-proof container is the correct action for safe disposal.
Choice D rationale:
Removing the needle from the syringe may be necessary for disposal but should be done carefully and in accordance with safety protocols.
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