A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

Palpate

Auscultate

Percuss

Answer and Explanation

The Correct Answer is A

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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Correct Answer is C

Explanation

A. Wearing sterile gloves when moving sterile items is appropriate practice and should not be intervened with.

B. Positioning the wrapped package so the outer flap is away from the nurse is correct to prevent contamination when opening.

C. The nurse should avoid holding sterile items too far above the sterile field to prevent contamination from falling or being exposed to non-sterile areas. Items should be held as close as possible to the sterile field, typically no more than 2 inches (5 cm).

D. Holding the bottle of solution with the label away from the palm of the hand is proper to maintain sterility.

A. Place the client in a room with negative airflow. B. Wear a gown when providing care to the client. C. Ensure the client's room has HEPA filtration. D. Wear a mask when providing care to the client.

Correct Answer is D

Explanation

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Nursing Test Bank

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