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 A
Explanation
A. A respiratory rate of 7/min is below the normal range and may indicate opioid- induced respiratory depression, which is a life-threatening complication requiring immediate intervention.
B. While important, a distended bladder does not pose an immediate threat to the client's life compared to respiratory depression.
C. Constipation is a common side effect of opioid medications but does not require immediate intervention unless accompanied by severe symptoms such as fecal impaction or bowel obstruction.
D. Pain management is important, but respiratory depression takes priority as it can lead to respiratory arrest and death.
Correct Answer is B
Explanation
A. Cooling the solution is not necessary and may cause discomfort to the client.
B. Using a syringe with a catheter allows for precise and controlled irrigation of the wound, helping to remove debris and promote healing.
C. Wearing a fresh pair of gloves for irrigation helps prevent contamination and reduces the risk of infection.
D. Administering analgesia may help manage pain during the procedure, but it is not directly related to the technique of wound irrigation.
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