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 B
Explanation
Choice A reason:
Performing percussion over the lower back: While percussion is part of the postural drainage technique, the specific areas to be percussed depend on the client's individualized care plan, which is based on the location of lung segments affected by cystic fibrosis. The nurse should follow the care plan and target the appropriate lung segments for percussion.
Choice B reason:
Covering the area of percussion with a towel is correct. When performing postural drainage with percussion and vibration for a client with cystic fibrosis, it is important to cover the area of percussion with a towel. This helps protect the client's skin and prevent discomfort or injury during the procedure. The towel acts as a barrier between the nurse's hand and the client's skin, allowing for effective percussion while minimizing friction and pressure
Choice Creason:
Scheduling postural drainage after meals: Postural drainage is ideally performed before meals or at least 1-2 hours after meals to avoid potential discomfort or vomiting due to the positioning and movement during the procedure.
Choice Dreason:
Instructing the client to exhale quickly during vibration: Vibration is typically performed during the client's exhalation phase, but the instruction should focus on slow, controlled exhalation rather than quick exhalation.
Correct Answer is ["A","B","C","E","F"]
Explanation
Client Symptoms:
- Urinary Symptoms: The client reports a 2-day history of urinary frequency, burning on urination, and both lower back and suprapubic pain.
- Fever: The client states they developed a fever this morning.
Urinalysis Results:
- Appearance: Cloudy urine.
- Leukocyte Esterase: Positive, indicating the presence of white blood cells.
- Nitrites: Present, suggesting bacterial infection.
Assessment:
- These findings strongly suggest a Urinary Tract Infection (UTI). The combination of urinary symptoms, fever, and urinalysis results supports this diagnosis.The nurse should promptly report these findings to the healthcare provider to ensure timely intervention.
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