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
While saturated fats are part of the body's metabolic processes, their primary negative impact at elevated levels isn't directly interfering with the overall metabolic pathways in a disruptive manner. The issue lies more specifically with their influence on lipid profiles rather than a broad metabolic dysfunction.
Choice B rationale
Saturated fats, primarily found in animal products, have been shown to increase low-density lipoprotein (LDL) cholesterol levels in the blood. Elevated LDL cholesterol is a major risk factor for atherosclerosis, a condition where plaque builds up in the arteries, narrowing them and increasing the risk of heart disease and stroke.
Choice C rationale
Hydrogenation is a process used to solidify unsaturated fats, creating trans fats, which are even more detrimental to cholesterol levels than saturated fats. Saturated fats themselves are naturally solid at room temperature and do not inherently need to be hydrogenated to achieve this state.
Choice D rationale
Saturated fats do not typically block the absorption of essential nutrients. The digestive system is designed to absorb a variety of fats, including saturated fats, along with other nutrients. The primary concern with high intake of saturated fats is their negative impact on blood lipid levels.
Correct Answer is ["200"]
Explanation
Step 1 is: The total volume to be infused is 50 mL.
Step 2 is: The infusion time is 15 minutes.
Step 3 is: To find the milliliters per hour, first convert minutes to hours: 15 minutes ÷ 60 minutes/hour = 0.25 hours.
Step 4 is: Calculate the infusion rate in mL/hour: 50 mL ÷ 0.25 hours = 200 mL/hour. The nurse will infuse the drug at 200 mL per hour.
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