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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. This represents a situational loss, as it is related to external circumstances such as economic changes.
B. This also represents a situational loss, as it involves the loss of material possessions.
C. This is a situational loss, specifically a loss of a loved one, which is different from a maturational loss.It is unexpected andoccurs due to an external event or situation.
D. This is an example of a maturational loss, as it involves a normal life transition that brings about feelings of loss and adjustment.

A. Hold the dropper 3 cm (1.2 in) away from the client's eye. B. Massage the client's eyelids for 20 seconds after instillation. C. Wait 5 min between the administration of each medication. D. Ask the client to close their eyes tightly after instilling each medication.

Correct Answer is C

Explanation

A. The dropper should be held about 1 cm (0.4 in) away from the eye to avoid touching or injuring the eye or contaminating the dropper tip.
B. Massaging the eyelids after instillation is not a standard practice and may cause discomfort or injury to the eye.
C. Administering multiple ophthalmic medications requires a sufficient interval between doses to prevent interactions and ensure effectiveness.
D. Asking the client to close their eyes tightly may squeeze out some of the medication or increase intraocular pressure.

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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.)

Nursing Test Bank

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A community health nurse is caring for a group of families. The nurse should identify that which of the following families is experiencing a maturational loss?

Correct Answer is D

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A nurse is administering multiple types of ophthalmic drops to a client. Which of the following actions should the nurse take?

Correct Answer is C

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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.)