A nurse is performing an abdominal assessment for a client. Which of the following findings should the nurse identify as the priority?
Gurgling bowel sounds every 10 seconds
Centrally located umbilical protrusion
Abdominal distention during breathing
Rebound tenderness with palpation
The Correct Answer is D
Choice A reason: Gurgling bowel sounds every 10 seconds are considered normal, as normoactive bowel sounds range from 5 to 30 sounds per minute. This finding indicates regular gastrointestinal activity and is not typically a cause for concern.
Choice B reason: A centrally located umbilical protrusion can be a normal finding, especially if it has been present since birth and is not associated with any other symptoms. However, if new or associated with pain or other symptoms, it could indicate a hernia or other pathology.
Choice C reason: Abdominal distention during breathing can be a normal finding, as the abdomen may distend slightly during deep breathing due to the movement of the diaphragm. However, if the distention is pronounced or associated with other symptoms, it may warrant further investigation.
Choice D reason: Rebound tenderness with palpation is a sign of peritoneal irritation and can be an indication of conditions such as appendicitis, which is a surgical emergency. This finding should be considered a priority as it may require immediate intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: A client with diabetes mellitus presenting with acute ketoacidosis does not necessarily require a private room unless there are other infection control concerns. Acute ketoacidosis is a metabolic complication of diabetes that can be managed in a general ward setting with appropriate medical care and monitoring.
Choice B reason: An older adult client admitted with aspiration pneumonia would benefit from a private room if the pneumonia is caused by an infectious agent that requires droplet or airborne precautions. However, aspiration pneumonia is often a result of inhaling food, stomach acid, or saliva into the lungs, and not always infectious.
Choice C reason: A client with a compound fracture of the right femur would require a private room if there is an associated risk of infection due to the open nature of the injury. However, standard precautions and wound care can often be managed in a semi-private or general ward setting unless there are specific infection control issues.
Choice D reason: A client reporting fever, night sweats, and cough for 2 days may be exhibiting symptoms of a communicable disease such as tuberculosis. This client would require a private room with airborne precautions to prevent the spread of infection to other patients and healthcare workers.
Correct Answer is A
Explanation
Choice A reason: Checking the pulse distal to the graft is essential to ensure that the graft is patent and that there is adequate blood flow to the distal extremity. A palpable pulse indicates that the graft is functioning properly and not occluded. The absence of a pulse could signify a serious complication, such as thrombosis or stenosis, which requires immediate attention.
Choice B reason: Keeping the left forearm below the level of the heart is not recommended as it can increase venous pressure and swelling, potentially compromising graft function. The extremity should be kept at or above heart level to promote venous return and reduce the risk of edema.
Choice C reason: Collecting blood specimens from the graft is generally avoided to prevent damage to the graft. Blood draws can be performed from other sites to protect the integrity of the graft.
Choice D reason: Splinting the left forearm is not a standard postoperative care measure for an arteriovenous graft. While protecting the graft from injury is important, immobilization with a splint is not necessary and can impede mobility and circulation.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.