A clinical instructor is reviewing the abdominal assessment with a group of students.
She would include which of the following three percussion sounds the nurse would expect to hear? (Select 3 options)

Hyperresonance.

Flatness.

Dullness.

Resonance.

Tympany.

Answer and Explanation

Correct Answer : B,E,C

Choice A rationale

Hyperresonance is a booming sound elicited during percussion, typically heard over hyperinflated lung tissue, such as in emphysema or pneumothorax. In the abdominal assessment, hyperresonance is generally not an expected finding and may indicate gaseous distension.

Choice B rationale

Flatness is a dull, very soft sound with a short duration, usually heard over dense tissues such as bone or muscle. In the abdomen, flatness is not a typical percussion sound and might be elicited over a large tumor or organomegaly.

Choice C rationale

Dullness is a thud-like sound with a medium intensity and duration, typically heard over solid organs such as the liver, spleen, or a distended bladder. In the abdominal assessment, dullness is an expected finding over these organs.

Choice D rationale

Resonance is a hollow sound of moderate duration and low pitch, typically heard over normal lung tissue. Resonance is not an expected percussion sound in the abdominal assessment; tympany and dullness are the predominant sounds.

Choice E rationale

Tympany is a drum-like sound with high pitch and longer duration, commonly heard over air-filled structures such as the stomach and intestines. Tympany is the predominant percussion sound expected over most of the abdomen due to the presence of gas in the gastrointestinal tract.

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Correct Answer is C

Explanation

Choice A rationale

Breathing in and out normally does not protect the airway during nasogastric tube removal. The risk of aspiration is present as the tube is withdrawn, and normal breathing does not actively close off the trachea.

Choice B rationale

Taking a deep breath and coughing can help to clear the airway after the tube is removed but does not directly aid in preventing aspiration during the removal process itself. Coughing expels material from the lungs and throat.

Choice C rationale

Holding her breath during nasogastric tube removal helps to close the epiglottis, which covers the trachea. This action minimizes the risk of aspiration of any residual secretions or reflux that might occur as the tube is being withdrawn.

Choice D rationale

Bearing down, or performing the Valsalva maneuver, increases intra-abdominal pressure and is typically used to stimulate a bowel movement. It is not relevant to protecting the airway during nasogastric tube removal and could potentially increase the risk of reflux.

A. Energy. B. Electrolytes. C. Minerals. D. Vitamins.

Correct Answer is A

Explanation

Choice A rationale

Carbohydrates are the body's primary source of energy. They are broken down into glucose, which cells use for fuel to perform various functions, including muscle contraction, nerve impulse transmission, and maintaining body temperature.

Choice B rationale

Electrolytes, such as sodium, potassium, and chloride, are minerals that carry an electrical charge and are crucial for fluid balance, nerve function, and muscle contraction. While some foods containing carbohydrates may also contain electrolytes, providing energy is not their primary function. Normal ranges for serum sodium are 135-145 mEq/L, potassium is 3.5-5.0 mEq/L, and chloride is 95-105 mEq/L.

Choice C rationale

Minerals are inorganic substances that the body needs for various functions, including building strong bones, transmitting nerve impulses, and maintaining fluid balance. Examples include calcium, iron, and zinc. While essential, they are not primarily known for providing direct energy. Normal ranges for serum calcium are 8.5-10.5 mg/dL, iron varies by gender (males: 65-175 mcg/dL, females: 50-170 mcg/dL), and zinc is 70-120 mcg/dL.

Choice D rationale

Vitamins are organic compounds that the body needs in small amounts for various metabolic processes. They do not directly provide energy but help the body utilize energy from carbohydrates, fats, and proteins. Examples include vitamin C, vitamin D, and B vitamins. Normal ranges vary widely depending on the specific vitamin.

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A clinical instructor is reviewing the abdominal assessment with a group of students.She would include which of the following three percussion sounds the nurse would expect to hear? (Select 3 options)

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A clinical instructor is reviewing the abdominal assessment with a group of students.
She would include which of the following three percussion sounds the nurse would expect to hear? (Select 3 options)