A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Percuss all four quadrants of the abdomen to measure sound quality.
Provide adequate lighting to inspect the abdomen.
Listen to the abdominal arteries using the bell of a stethoscope.
Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen.
Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.
The Correct Answer is B, C, E, D, A
B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.
C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.
E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.
D.Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Discarding the needle in a puncture-proof container is the correct action to be taken. After administering an injection, the nurse should immediately dispose of the needle in a puncture-proof container. This helps prevent needlestick injuries and ensures proper disposal of sharp objects.
Choice B reason:
Removing the needle from the syringe is inappropriate because it could increase the risk of a needlestick injury. Needles should be discarded as a unit with the syringe.
Choice C reason:
Placing the needle on the bedside table is not a safe practice and can lead to accidental needlestick injuries.
Choice D reason:
Recapping the needle before disposal is not recommended, as it increases the risk of needlestick injuries. Many healthcare organizations discourage recapping due to the potential for accidental needle sticks. If recapping is required by local policy, it should be done using a safe method.
Correct Answer is ["A","B","C","D"]
Explanation
a small amount of serosanguineous drainage,
Lung sounds are diminished in posterior lobes,
pain as 8 on a scale of 0 to 10,
Blood pressure 168/84 mm Hg
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