A nurse inspects the abdomen for skin color, contour, surface characteristics, and symmetry.
What part of the abdominal assessment does the nurse perform next?
Light palpation for tenderness and muscle tone.
Auscultation of the bowel sounds in all four quadrants.
Percussion for tones in all four quadrants.
Deep palpation for masses or aortic pulsations.
The Correct Answer is B
Choice A rationale
Light palpation is typically performed after auscultation to assess for superficial tenderness, muscle tone, and pulsations. Auscultation precedes palpation to avoid inducing artificial bowel sounds or altering existing ones due to manual pressure.
Choice B rationale
Auscultation of bowel sounds in all four quadrants is the next step in the abdominal assessment after inspection. Listening to bowel sounds provides information about the motility of the gastrointestinal tract and should be done before palpation or percussion, which can alter these sounds.
Choice C rationale
Percussion for tones in all four quadrants is usually performed after auscultation and before palpation. Percussion helps to assess the size and density of abdominal organs and to identify the presence of fluid or air.
Choice D rationale
Deep palpation is performed last in the abdominal assessment sequence to evaluate for deeper masses and aortic pulsations. It follows inspection, auscultation, and light palpation, allowing the nurse to gather preliminary information before applying deeper pressure. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Canned tuna and salmon, while sources of protein and omega-3 fatty acids, are not particularly high in potassium. Clients taking potassium-wasting diuretics need foods rich in potassium to replace the electrolytes lost through increased urination.
Choice B rationale
Oranges and bananas are excellent sources of potassium. Potassium is an essential electrolyte that is often depleted by potassium-wasting diuretics like furosemide or hydrochlorothiazide. Consuming these fruits helps maintain adequate potassium levels, which are crucial for cardiac function and muscle contraction. The normal range for serum potassium is typically 3.5-5.0 mEq/L.
Choice C rationale
Dried fruits, such as apricots and raisins, are high in potassium. However, the question asks what the nurse *should* include, and while dried fruits are beneficial, fresh fruits like oranges and bananas are often more readily available and consumed in larger quantities.
Choice D rationale
Cow's milk contains potassium but is not specifically emphasized for clients on potassium-wasting diuretics. Other food sources like fruits and vegetables generally provide a more direct and often higher concentration of potassium without the added phosphorus and calcium found in milk, which may be considerations for some individuals.
Correct Answer is D
Explanation
Choice A rationale
Green leafy vegetables are excellent sources of vitamins, minerals, and fiber, which are crucial for overall health during breastfeeding. However, they are not primary sources of complete protein, which contains all nine essential amino acids needed for milk production and maternal tissue repair.
Choice B rationale
Citrus fruits and juices are rich in vitamin C and provide hydration, which are important during breastfeeding. However, they are primarily sources of carbohydrates and micronutrients and do not offer significant amounts of protein necessary for increased protein intake during lactation.
Choice C rationale
White bread, rice, and potatoes are primarily sources of carbohydrates, providing energy. While they contribute to the overall caloric intake needed during breastfeeding, they are low in protein and do not offer the essential amino acids required in higher amounts for milk production and maternal needs.
Choice D rationale
Nuts, turkey breast, and lean meats are excellent sources of complete protein, providing all the essential amino acids required by a breastfeeding mother and her infant. These foods support milk production, tissue repair, and overall nutritional needs during lactation, making them healthy choices for increasing protein intake.
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