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 A

Explanation

Choice A reason:
False imprisonment is the correct answer because it occurs when a person intentionally restricts the freedom of movement of another person without proper consent or legal justification. In this scenario, the AP is threatening to place the client in restraints against their will if they do not comply with bed rest. This action is a violation of the client's rights and constitutes false imprisonment.
Choice B reason:
Defamation of character is incorrect: Defamation involves making false statements about someone that harm their reputation. It doesn't apply to this scenario.
Choice C reason:
Battery is incorrect: Battery involves intentional harmful or offensive physical contact with another person without their consent. There is no indication of physical contact in this situation.
Choice D reason:
Assault is incorrect. Assault refers to the intentional threat or act that causes fear of imminent harmful or offensive contact. While there is a threat implied in this scenario, the threat is of false imprisonment rather than physical harm, making false imprisonment a more accurate description of the tort.

A. Sodium 140 mEq/L B. Potassium 5.8 mEq/L C. Calcium 9.6 mg/dL D. Magnesium 1.9 mEq/L

Correct Answer is B

Explanation

Choice A reason:

Sodium 140 mEq/L is incorrect because it falls within the normal range (135-145 mEq/L).

Choice B reason:

A potassium level of 5.8 mEq/L is appropriate because it is above the normal range (typically around 3.5-5.0 mEq/L). Elevated potassium levels, known as hyperkalaemia, can lead to serious cardiac disturbances, including arrhythmias or even cardiac arrest. It is important to notify the healthcare provider promptly so that appropriate interventions can be initiated to address the high potassium level.

Choice C reason:

Calcium 9.6 mg/dL is incorrect because it is within the normal range (8.5-10.5 mg/dL).

Choice D reason:

Magnesium 1.9 mEq/L is incorrect because it is within the normal range (1.5-2.5 mEq/L).

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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.)

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is reviewing the medical record for a newly admitted client. Which of the following laboratory values should the nurse report to the provider?

Correct Answer is B

Explanation

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