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 flat, nonpalpable, dark-colored area of skin on the trunk is likely a benign nevus, or mole, that does not pose a serious threat.
Choice B rationale:
An atrophic wart on the left index finger is also a benign growth that can be removed by cryotherapy or surgery.
Choice C rationale:
Skin tags in the nose region are harmless skin protrusions that are common in older adults and can be removed for cosmetic reasons.
Choice D rationale:
The nurse's priority is to assess the mole on the shoulder that has changed in appearance. This could indicate a malignant melanoma, which is a type of skin cancer that can spread quickly and be fatal.
Correct Answer is D
Explanation
Rationale for A: Drawing the short-acting insulin into the syringe should not be done before preparing the vials.
Rationale for B: Injecting air into the short-acting insulin vial is not the first step in the procedure.
Rationale for C: Drawing the intermediate-acting insulin into the syringe should only be done after injecting air into the intermediate-acting insulin vial first.
Rationale for D: Injecting air into the intermediate-acting insulin vial first is essential because it helps prevent a vacuum and ensures accurate measurement of the insulin when drawing it into the syringe. This step is part of the correct procedure for mixing insulins.
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