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 A

Explanation

A. A vision of 20/30 means that the patient can read at 20 feet what a person with normal vision can read at 30 feet, indicating mild visual impairment.

B. This reverses the explanation of 20/30 vision and is incorrect.

C. This option incorrectly describes the Snellen chart results, which measure clarity of vision at specific distances, not entire chart reading ability.

D. This option confuses visual acuity for each eye; Snellen scores do not indicate different distances for each eye.

A. Shield the lips so that the sound is muffled. B. Whisper a set of random numbers and letters, and then ask the patient to repeat them. C. Ask the patient to place his finger in his ear to occlude outside noise. D. Stand approximately 4 feet away to ensure that the patient can really hear at this distance.

Correct Answer is B

Explanation

A. Shield the lips: Shielding the lips ensures the patient is not lip-reading but should not muffle the sound.

B. Whisper random numbers and letters: The whisper test involves standing behind the patient, whispering a series of numbers and letters, and asking the patient to repeat them.

C. Occlude outside noise: Asking the patient to occlude one ear may alter test results.

D. Stand approximately 4 feet away: The whisper test is typically performed from 1-2 feet behind the patient.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that:

Correct Answer is A

Explanation

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Correct Answer is B

Explanation

The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia?

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When performing a peripheral vascular assessment of the lower extremities, a nurse should place the fingertips just posterior to the medial malleolus in order to assess for which of the following peripheral pulses?

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