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A nurse is caring for a client in a surgical recovery unit.

Exhibits

Drag the words from the choices below to fill in each blank in the following sentence

To effectively conduct an abdominal assessment, a nurse should

, and in the correct order
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"F","dropdown-group-2":"A","dropdown-group-3":"D"}

Rationale for correct choices:

  • Inspect the abdomen: Visual inspection is the first step to identify distention, asymmetry, scars, or visible peristalsis, providing a baseline for further assessment.
  • Auscultate for bowel sounds: Auscultation is performed before palpation to avoid stimulating the bowel, which could alter bowel sounds. It identifies hypoactive, hyperactive, or absent bowel activity.
  • Palpate for tenderness: Palpation is performed last to assess for tenderness, masses, or guarding, ensuring patient comfort and preventing interference with bowel sound assessment.

Rationale for incorrect choices:

  • Percuss the abdomen: Percussion can assess for fluid or organ size but is not part of the standard initial sequence for abdominal assessment. While percussion is a valid part of an abdominal exam (used to identify fluid, air, or organ size), it should follow auscultation and precede deep palpation. In this specific question, "auscultate" and "palpate" are higher-priority steps for identifying the hypoactive sounds and firmness noted in the nurse's notes.
  • Check for costovertebral angle tenderness: This evaluates kidney tenderness and is not routinely included in a general abdominal assessment unless renal pathology is suspected.
  • Measure abdominal girth: This may be used to monitor changes in distention but is not part of the primary sequential abdominal assessment.


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Related Questions

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Explanation

Rationale for correct choices:

  • Deep vein thrombosis: The client’s limited mobility, recent hip fracture, and unilateral calf swelling and warmth significantly increase the risk for DVT. Immobility reduces venous return, promoting clot formation in the lower extremities, making early assessment and preventive measures critical.
  • Pulmonary embolism: A DVT can dislodge and travel to the lungs, causing a potentially life-threatening pulmonary embolism. Monitoring for signs such as sudden shortness of breath, chest pain, or hypoxia is essential to prevent serious complications.

Rationale for incorrect choices:

  • Diarrhea: There is no evidence of gastrointestinal upset, increased bowel movements, or infection that would place the client at risk for diarrhea.
  • Hypertension: The client’s vitals do not indicate elevated blood pressure, and there are no factors in the scenario suggesting risk for acute hypertension.
  • Hypocalcemia: The client’s lab results do not indicate low calcium levels, and there are no signs or symptoms suggestive of hypocalcemia, making this an unlikely risk.

Correct Answer is C

Explanation

A. Shake the NPH insulin until it is well mixed: NPH insulin should be gently rolled between the palms, not shaken vigorously, to avoid creating bubbles and affecting its potency. Gentle mixing ensures proper suspension without compromising the insulin.

B. Draw up the NPH insulin into the syringe first: The correct technique is to draw up regular (clear) insulin first, followed by NPH (cloudy) insulin, to prevent contaminating the regular insulin with the longer-acting NPH. Drawing NPH first can alter the regular insulin’s action.

C. Inject air into the regular insulin first: Injecting air into both insulin vials before drawing up doses equalizes pressure and facilitates accurate measurement. Air is injected first into the regular insulin vial to maintain proper technique when mixing insulins.

D. Discard regular insulin that appears cloudy: Regular insulin is a clear solution. Cloudiness indicates contamination or expiration, so cloudy regular insulin should never be used. This instruction reinforces proper medication safety practices.

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