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.)

Observe the contours of the client’s abdomen using a penlight.

Determine the presence of bowel sounds by using the diaphragm of the stethoscope.

Systematically percuss the client’s abdomen.

Use fingertips to lightly depress the right lower quadrant of the client’s abdomen.

Press deeply into the client’s upper abdomen left of midline to detect aortic pulsation.

Answer and Explanation

The Correct Answer is A,B,C,D,E

Choice A reason:

Observing the contours of the client’s abdomen using a penlight is the first step in the abdominal assessment. This step involves inspecting the shape, skin abnormalities, masses, and movement of the abdomen. It is essential to perform this step first to gather initial visual information about the abdomen’s condition before proceeding to other assessment techniques.

Choice B reason:

Determining the presence of bowel sounds by using the diaphragm of the stethoscope is the second step in the abdominal assessment. Auscultation should be performed before percussion and palpation to avoid altering the frequency and intensity of bowel sounds. This step helps assess the presence, frequency, and location of bowel sounds, as well as any vascular sounds.

Choice C reason:

Systematically percussing the client’s abdomen is the third step in the abdominal assessment. Percussion helps assess the presence of tympany or dullness, which can indicate the presence of air, fluid, or solid masses in the abdomen. This step provides valuable information about the underlying structures and any abnormalities.

Choice D reason:

Using fingertips to lightly depress the right lower quadrant of the client’s abdomen is the fourth step in the abdominal assessment. Light palpation helps assess the consistency, tenderness, and presence of any masses or rigidity in the abdomen. This step should be performed after percussion to avoid altering the findings.

Choice E reason:

Pressing deeply into the client’s upper abdomen left of midline to detect aortic pulsation is the fifth and final step in the abdominal assessment. Deep palpation helps assess the presence of any deep-seated masses and the aortic pulsation, which can provide information about the vascular status of the abdomen.

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Correct Answer is D

Explanation

Choice A Reason

Documenting the indications for using wrist restraints is an important step in the process, but it is not the first action the nurse should take. Documentation ensures that there is a clear rationale for the use of restraints and helps in maintaining legal and ethical standards1. However, before documenting, the nurse must explore and attempt less restrictive alternatives to ensure that restraints are truly necessary.

Choice B Reason

Obtaining a prescription for restraints from the provider is a crucial step, as restraints should only be used with a valid order from a healthcare provider. This ensures that the use of restraints is medically justified and that the provider is aware of the client’s condition. However, before seeking a prescription, the nurse must first attempt less restrictive alternatives to manage the client’s behavior.

Choice C Reason

Explaining the procedure to the client and their family is essential for informed consent and to ensure that they understand the reasons for using restraints. This step helps in maintaining transparency and trust. However, it should be done after the nurse has determined that less restrictive alternatives are not effective and that restraints are necessary.

Choice D Reason

Attempting less restrictive alternatives is the first action the nurse must take. This approach aligns with ethical and legal guidelines that emphasize the use of the least restrictive measures to ensure the client’s safety. Alternatives may include verbal de-escalation, environmental modifications, or the use of less restrictive devices. Only if these measures fail should the nurse consider using restraints.

A. Inform the provider of the delay in obtaining the type and cross-match. B. Document the incident in the client’s medical record. C. Prepare an incident report for risk management. D. Obtain the client’s type and cross-match.

Correct Answer is D

Explanation

Choice A Reason:

Informing the provider of the delay in obtaining the type and cross-match is important for keeping the healthcare team informed. However, this action should follow the immediate step of obtaining the type and cross-match to ensure the client has compatible blood available for surgery. Communication with the provider is crucial but secondary to addressing the immediate need.

Choice B Reason:

Documenting the incident in the client’s medical record is necessary for maintaining accurate records and ensuring continuity of care. However, this action should be performed after the immediate need for obtaining the type and cross-match is addressed. Accurate documentation is essential but not the first priority in this situation.

Choice C Reason:

Preparing an incident report for risk management is important for identifying and addressing potential system issues that led to the oversight. However, this action is not the immediate priority. The primary focus should be on obtaining the type and cross-match to ensure the client’s safety during surgery. Incident reporting can be done after the immediate needs are met.

Choice D Reason:

Obtaining the client’s type and cross-match is the first action the nurse should take because it ensures that the client will have compatible blood available for transfusion if needed during surgery. This step directly addresses the immediate clinical need and prioritizes the client’s safety and readiness for surgery.

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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

Naxlex Comprehensive Predictor Exams

A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

Correct Answer is D

Explanation

During change-of-shift report, a nurse discovers they overlooked a prescription for a type and cross-match of a client who is to have surgery the next day. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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