A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?
Auscultation
Inspection
Palpation
Percussion
The Correct Answer is C
Rationale:
A. Auscultation: This step is performed after inspection and before percussion or palpation to avoid altering bowel sounds. It allows the nurse to assess for the presence, frequency, and character of bowel sounds without stimulating them artificially.
B. Inspection: This is the first step in the abdominal assessment. It involves visually examining the abdomen for contour, symmetry, skin changes, pulsations, or visible masses without touching the patient, helping establish a baseline.
C. Palpation: Palpation is the final step in abdominal assessment to prevent interference with bowel sounds. It allows the nurse to detect tenderness, masses, or organ enlargement, but should only be done after auscultation and percussion.
D. Percussion: This is done after auscultation and provides information on underlying structures, such as gas, fluid, or masses. It helps differentiate between dullness, resonance, or tympany across abdominal quadrants.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. "Let's talk about what you already know about immunizing your baby.": This response uses open-ended, nonjudgmental communication to explore the parents' beliefs and knowledge. It encourages dialogue, builds trust, and opens the door for education about vaccine safety and benefits.
B. "Your baby's immunizations should be up to date before they are able to travel with you by airplane.": This statement may feel coercive or irrelevant if the parents are not currently planning to travel. It does not address their current concerns or promote open discussion.
C. "You don't have to immunize your baby against diseases that are no longer common.": Diseases like measles and pertussis can still occur and spread quickly in under-immunized communities. Vaccination remains essential to maintain herd immunity and prevent outbreaks.
D. "The provider can give you a referral for your baby to see an infectious disease provider.": Referring to a specialist at this stage may come across as dismissive or escalate the situation unnecessarily. Primary care providers and nurses can often address vaccine concerns effectively through discussion and education.
Correct Answer is []
Explanation
Rationale for Correct Choices
- Heart failure: The client’s symptoms bilateral crackles, +3 lower extremity edema, cool limbs with weak pulses, an S3 heart sound, and elevated BNP are classic signs of decompensated heart failure with volume overload and poor perfusion.
- Educate the client about sodium restriction: Sodium contributes to fluid retention and increased cardiac workload. Dietary sodium restriction is crucial in preventing fluid overload, thus reducing exacerbations of heart failure symptoms such as edema and dyspnea.
- Obtain a prescription for a diuretic: Diuretics like furosemide relieve volume overload by promoting fluid excretion. They help decrease pulmonary congestion, improve oxygenation, and reduce peripheral edema in heart failure patients.
- Daily weight: Monitoring weight helps detect subtle changes in fluid balance. A sudden weight gain of 2–3 pounds in 24 hours may signal worsening heart failure and the need for diuretic adjustment.
- Blood pressure: Blood pressure monitoring provides insight into cardiac output and guides medication titration. Both hypertension and hypotension can worsen outcomes in clients with heart failure.
Rationale for Incorrect Choices
- Endocarditis: This condition presents with fever, new or changing murmurs, petechiae, or positive blood cultures. The absence of infection signs and the presence of systemic fluid overload point away from endocarditis.
- Aortic stenosis: Typical signs include exertional dyspnea, syncope, chest pain, and a harsh systolic murmur not crackles, edema, or elevated BNP. This client’s profile better matches heart failure.
- Mitral stenosis: This condition may cause pulmonary congestion but often presents with a diastolic murmur and atrial fibrillation, which are not described here.
- Administer antibiotics as prescribed: Without clinical or laboratory signs of infection (fever, leukocytosis, or positive cultures), antibiotics are not appropriate for heart failure.
- Prepare the client for cardioversion: Cardioversion is used for arrhythmias like atrial fibrillation with rapid ventricular response. The client has a normal apical pulse and no dysrhythmia signs.
- Educate the client about valve replacement: Valve surgery is not indicated unless diagnostic findings confirm severe valvular disease. No murmur or echo data is provided here.
- Skin lesions: These are associated with endocarditis, not heart failure. Findings like Janeway lesions or Osler nodes are not reported in this case.
- Blood cultures: Indicated when bacteremia or endocarditis is suspected. Heart failure without infection signs does not warrant blood cultures.
- Fever: The client is afebrile, making infection less likely. Fever is not a feature of uncomplicated heart failure and does not need monitoring here.
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