A nurse is assessing a client's abdomen. In what order should the nurse complete the steps of the assessment? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Press deeply into the client's upper abdomen left of midline to detect aortic pulsation.
Use fingertips to lightly depress the right lower quadrant of the client's abdomen.
Systematically percuss the client's abdomen.
Observe the contours of the client's abdomen using a penlight
Determine the presence of bowel sounds by using the diaphragm of the stethoscope.
The Correct Answer is D,E,C,B,A
A. Deep palpation is the final step in an abdominal examination since it may elicit tenderness which may interfere with other aspects of examination.
B. This is the second last step just before deep palpation. It is used to detect any obvious masses or areas of tenderness.
C. Percussion is the third step in an abdominal examination where the nurse should percuss the client's abdomen systematically, tapping lightly on each area and noting the sound quality. It can be used to detect the presence of ascites which be stony dull on percussion.
D. Inspection is the first step where the nurse should inspect the contours of the client's abdomen using a penlight, looking for any abnormalities or distension.
E. Auscultation is the second step in an abdominal examination. The nurse should auscultate the client's abdomen using the diaphragm of the stethoscope, listening for bowel sounds in all four quadrants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A sore throat is not typically associated with a mild allergic reaction to antibiotics.
B. Urinary frequency is not typically associated with a mild allergic reaction to antibiotics.
C. Tinnitus is not typically associated with a mild allergic reaction to antibiotics.
D. Urticaria, or hives, is a common manifestation of a mild allergic reaction to antibiotics.
Correct Answer is D
Explanation
A. While a prescription may be necessary, attempting less restrictive alternatives should be the first action.
B. Documentation is important but should not precede attempting less restrictive alternatives.
C. Education about the use of restraints is important but should follow attempts at less restrictive alternatives.
D. The nurse should exhaust all possible alternatives to restraints before considering their use, in line with the principle of least restrictive intervention.
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