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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is C
Explanation
A. Administer antibiotic therapy to the client. This is a priority intervention, but it is not the first action. Before administration, infection control measures should be in place.
B. Provide the client with analgesics as needed. Pain management is important but is not the first priority. The spread of infection must be controlled immediately.
C. Initiate droplet precautions for the client. Meningococcal meningitis is highly contagious. Droplet precautions (mask, private room) must be initiated immediately to prevent transmission before other interventions.
D. Educate the client about the meningococcal vaccine. Vaccination is a preventive measure but does not address the immediate risk of infection spread.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.