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 B

Explanation

A. The Administration for Children and Families primarily handles welfare and family support programs, not HIPAA administrative provisions.

B. The Centers for Medicare and Medicaid Services (CMS) is responsible for implementing and administering many aspects of HIPAA related to health care providers, insurers, and payment systems.

C. The Social Security Administration manages social security programs but does not handle HIPAA administrative provisions.

D. The Health Resources and Services Administration is focused on improving access to health care for underserved populations, not directly responsible for HIPAA administration.

A. Document that the nurse was unable to measure the client's temperature. B. Wait 30 min and return to measure the oral temperature C. Proceed to measure the oral temperature. D. Provide the client a sip of warm water, wait 5 min, and measure the temperature.

Correct Answer is B

Explanation

A. Documenting that the nurse was unable to measure the temperature is unnecessary if the nurse can follow the correct procedure of waiting and measuring after a proper interval.

B. The nurse should wait at least 30 minutes after the client has eaten or consumed ice chips before measuring the oral temperature to ensure an accurate reading.

C. Proceeding immediately to measure the temperature after consuming ice chips may result in an inaccurate reading, as it can lower the temperature of the mouth.

D. Providing warm water and waiting 5 minutes may not be sufficient to correct the cooling effect of the ice chips on the oral cavity.

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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

Naxlex Comprehensive Predictor Exams

Which division of the United States Department of Health and Human Services is primarily responsible for the administrative provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?

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