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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. "Hold your breath for 6 seconds after inhaling the medication." – The correct recommendation is to hold the breath for at least 10 seconds to allow maximum medication absorption in the lungs.

B. "Inhale the medication deeply for 5 seconds." – A slow, deep inhalation (3-5 seconds) allows the medication to reach the lower airways effectively.

C. "Do not shake the medication in the inhaler." – Most metered-dose inhalers (MDIs) need to be shaken before use to ensure proper mixing of medication. Exceptions include dry powder inhalers (DPIs), which should not be shaken.

D. "Hold the inhaler 3 inches away from your mouth." – The correct distance is 1 to 2 inches (2-4 cm) from the mouth, or the mouthpiece can be placed directly into the mouth with lips sealed around it.

A. "I need to have an attorney sign my advance directives." B. "I have a living will that outlines my wishes if I am unable to make decisions." C. "I must have a family member appointed to make my health care decisions." D. "I will need to sign a document stating that I want to be resuscitated if I require CPR."

Correct Answer is B

Explanation

A. "I need to have an attorney sign my advance directives." An attorney is not required to sign an advance directive. The document typically requires the client’s signature and witnesses but does not need legal counsel unless state laws specify otherwise.

B. "I have a living will that outlines my wishes if I am unable to make decisions." A living will is a type of advance directive that specifies the client’s preferences for medical care if they become unable to make decisions. This statement shows understanding.

C. "I must have a family member appointed to make my health care decisions." While a client can appoint a family member as a healthcare proxy, it is not required. The client may choose any trusted individual to act as their healthcare power of attorney.

D. "I will need to sign a document stating that I want to be resuscitated if I require CPR." A Do Not Resuscitate (DNR) order is signed when a client chooses not to receive CPR. If the client wants resuscitation, no additional documentation is required—healthcare providers automatically provide life-saving measures unless a DNR order is in place.

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A nurse is preparing to perform a routine abdominal assessment for a client. Which of the following actions should the nurse take?

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