A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?
Document shiny, taut skin as an expected finding.
Perform palpation after auscultation.
Listen for 1 min before documenting absent bowel sounds.
Perform auscultation immediately after the client has consumed a meal.
The Correct Answer is B
A. Document shiny, taut skin as an expected finding. Shiny, taut skin may indicate ascites or fluid retention, which are abnormal findings.
B. Perform palpation after auscultation. Palpation should always follow auscultation to avoid altering bowel sounds.
C. Listen for 1 min before documenting absent bowel sounds. Bowel sounds are considered absent only after listening for at least 5 minutes in each quadrant.
D. Perform auscultation immediately after the client has consumed a meal. Post-meal auscultation may result in altered bowel sounds, making the assessment unreliable.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The client reports taking the medication 30 min before the prescribed time. Taking a medication slightly earlier is unlikely to significantly affect its therapeutic efficacy.
B. The client received an influenza vaccine 1 month ago. Vaccination does not interfere with arthritis medications unless it triggers an immune response leading to disease flare-up, which is rare.
C. The client reports taking the medication with room temperature water. The temperature of the water does not impact the drug’s effectiveness.
D. The client has a history of recurring bowel inflammation. Chronic bowel inflammation (e.g., Crohn’s disease) can affect drug absorption, reducing medication effectiveness.
Correct Answer is A
Explanation
A. "The body produces antibodies in response to an antigen with active immunity." Active immunity develops after exposure to an antigen, leading to antibody production.
B. "There is lifelong immunity with passive immunity." Passive immunity is temporary (e.g., maternal antibodies).
C. "The body is able to recognize previous exposure to antigens with passive immunity." Passive immunity does not create immune memory.
D. "There is a short duration of immunity with active immunity." Active immunity is long-lasting and sometimes lifelong.
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