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 B

Explanation

A. Normal finding: This is not a normal finding. Dullness in this area could indicate an enlarged liver (hepatomegaly), which requires further evaluation.

B. Enlarged liver: Dullness above the right costal margin, especially around 11 cm, is often associated with hepatomegaly. The nurse should refer the patient to a physician for further investigation.

C. Hepatomegaly: While the finding could suggest hepatomegaly, the diagnosis should be confirmed by a physician. The nurse should refer the patient for further evaluation.

D. Alcohol intake: While it is relevant to ask about alcohol intake in the context of liver health, the immediate action is to refer the patient for further examination by a physician.

A. Posterior tibial B. Femoral C. Popliteal D. Dorsalis pedis

Correct Answer is A

Explanation

A. Posterior tibial: The posterior tibial pulse is palpated just posterior to the medial malleolus (inner ankle).

B. Femoral: The femoral pulse is assessed in the groin area, not near the ankle.

C. Popliteal: The popliteal pulse is located behind the knee, not near the ankle.

D. Dorsalis pedis: The dorsalis pedis pulse is palpated on the top of the foot, not near the ankle.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he "can't always tell where the sound is coming from" and the words often sound "mixed up." What might the nurse suspect as the cause for this change?

During an eye examination, a client tells a nurse that their left eye feels dry and itchy and has noticed a lot of tearing. The nurse notices that the client's left lower eyelid is rolled out with exposure of the palpebral conjunctiva. The nurse would document these findings as:

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