A nurse is precepting a new graduate nurse on the telemetry unit. The new graduate nurse is preparing to perform an abdominal assessment on a hospitalized client without a history of gastrointestinal abnormalities. Click to indicate the corresponding number for each of the following assessment techniques in order of performance.

Percussion

Inspection

Palpation

Auscultation

Answer and Explanation

The Correct Answer is {"A":{"answers":"D"},"B":{"answers":"A"},"C":{"answers":"C"},"D":{"answers":"B"}}

Assessment Technique	1	2	3	4
Percussion				✅
Inspection	✅
Palpation			✅
Auscultation		✅

Rationale:

Begin with inspection to visually assess the abdomen for abnormalities. Auscultate before palpation and percussion to avoid altering bowel sounds. Determine areas of pain to avoid causing discomfort during palpation and percussion. Palpate to assess for tenderness or masses. Percuss last to evaluate organ size and detect abnormal fluid or gas.

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Correct Answer is D

Explanation

A. Subjective vertigo: Subjective vertigo refers to the sensation of being dizzy but without the room spinning. The patient described the sensation of the room spinning.

B. Tinnitus: Tinnitus refers to a ringing or buzzing sound in the ears, not the sensation of the room spinning.

C. Dizziness: Dizziness can refer to a range of symptoms, but the description of the room spinning suggests vertigo, not just dizziness.

D. Objective vertigo: Objective vertigo refers to the sensation that the room is spinning, which the patient describes. This is typically a vestibular issue involving the inner ear.

A. Pallor of the toes and cyanosis of the nail beds B. Thin, shiny, atrophic skin C. Brownish discoloration to the skin of the lower leg D. Unilateral cool foot

Correct Answer is C

Explanation

A. Pallor and cyanosis: Indicative of arterial insufficiency, not venous disease.

B. Thin, shiny skin: Seen in peripheral arterial disease (PAD).

C. Brownish discoloration: Caused by hemosiderin deposits from chronic venous congestion.

D. Unilateral cool foot: Suggests acute arterial obstruction.

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Naxlex Comprehensive Predictor Exams

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" The nurse notices that the patient is experiencing:

Correct Answer is D

Explanation

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

Correct Answer is C

Explanation

Which of the following should the nurse perform to assess the arterial function of the lower extremities?

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply)

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

The nurse gave a client an instruction sheet for a colonoscopy. The client held the instructions approximately 18 inches from their face and read the description of the procedure aloud. The nurse recognizes that the client

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. How should the nurse proceed?

During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?