A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "I trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?
Notify the provider.
Provide brochures about the procedure.
Describe the surgery to the client.
Complete an incident report
The Correct Answer is A
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is E,C,D,B,A
Explanation
To perform a physical assessment of a client's abdomen, the nurse should follow the following sequence:
1. Provide adequate lighting to inspect the abdomen.
2. Listen to the abdominal arteries using the bell of a stethoscope.
3. Percuss all four quadrants of the abdomen to measure sound quality.
4. Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen.
5. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.
Correct Answer is A
Explanation
The tracheostomy ties should be secure enough to keep the tracheostomy tube in place but loose enough to allow for proper circulation and prevent skin breakdown. Allowing one finger to fit snugly underneath ensures that the ties are not too tight, which can compromise blood flow
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