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.

Answer and Explanation

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

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Correct Answer is B

Explanation

Choice A reason:
Powdered gloves are more likely to release latex particles into the air, which can increase the risk of exposure for a client with a latex allergy. Therefore, using non-powdered gloves is recommended.
Choice B reason:
Scheduling the client as the first surgical procedure of the day is the appropriate action because it can help minimize the risk of latex exposure. This is because latex particles released into the air during previous surgeries can settle in the surgical environment, increasing the risk for individuals with latex allergies. By scheduling the client's surgery as the first procedure, the likelihood of exposure to residual latex particles is reduced.
Choice C reason:
Removing the stopcocks from IV tubing does not directly address the risk of latex exposure in a surgical setting.
Choice D reason:
Cleansing stoppers with povidone-iodine is a good practice for infection control but does not specifically address the risk of latex exposure for a client with a latex allergy during surgery.

A. The client has an implanted defibrillator. B. The client is allergic to penicillin. C. The client has a history of alcohol use disorder. D. The client has a prescription for metoprolol.

Correct Answer is A

Explanation

Choice A reason
The client has an implanted defibrillator is the correct answer. Magnet therapy involves the use of magnets to alleviate pain and promote healing. However, it is contraindicated for individuals with implanted electronic devices, such as pacemakers or defibrillators, as the magnetic field could potentially interfere with the functioning of these devices. The safety of using magnet therapy with implanted devices has not been established, and caution is advised.
Choice B reason:
Allergic to penicillin is incorrect. Allergies to penicillin or other substances are not related to the use of magnet therapy.
Choice C reason:
The history of alcohol use disorder is incorrect. A history of alcohol use disorder does not directly contraindicate the use of magnet therapy.
Choice D reason:
The prescription for metoprolol is incorrect. Metoprolol is a common medication used to treat various conditions, including hypertension and certain heart conditions. It is not a contraindication for magnet therapy.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions is appropriate to include in the client's plan of care?

Correct Answer is B

Explanation

A nurse is reviewing the medical record of a client who asks about the use of magnet therapy for pain relief. The nurse should identify that which of the following findings is a contraindication for receiving this type of therapy?

Correct Answer is A

Explanation

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