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. 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.

A. Motor impairment B. Pain C. The client's culture D. Hearing loss

Correct Answer is B

Explanation

A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

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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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