A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Superficial palpation

Auscultation

Inspection

Deep palpation

Answer and Explanation

The Correct Answer is C, B, A, D

Inspection: This is the first step because it allows the nurse to gather information through observation without causing any discomfort to the child. It involves looking at the child's abdomen for any visible abnormalities like distension, asymmetry, masses, or discoloration.

Auscultation: After inspection, the nurse listens to the bowel sounds using a stethoscope. This helps assess peristalsis (movement of food through the intestines) and identify potential problems like bowel obstruction or decreased motility.

Superficial Palpation: This gentle palpation helps assess muscle tone, tenderness, and masses. It's performed after auscultation to avoid altering bowel sounds. Since children are often apprehensive about abdominal exams, starting with a gentler touch can help them feel more comfortable.

Deep Palpation (if necessary): Deep palpation is reserved for last as it can be more uncomfortable for the child. It's used to assess for organomegaly (enlarged organs) or masses that may not be palpable with superficial palpation. It's only performed if there are indications from the first three steps.

Here's a breakdown of why this order is important:

Minimize Discomfort: Starting with non-invasive methods like inspection and auscultation helps establish trust and reduces anxiety in the child, making the overall assessment more cooperative.

Maintain Baseline Bowel Sounds: Palpation can alter bowel sounds, so it's important to listen to them first to get an accurate baseline.

Gradual Progression: Moving from gentle to deeper palpation allows the child to adjust to the sensation and helps the nurse identify potential areas of tenderness before applying deeper pressure.

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Free Nursing Study Resources

Correct Answer is ["A","C"]

Explanation

A. Apply petroleum jelly to the client's lips after oral care: Applying petroleum jelly to the client's lips can help prevent dryness and cracking, particularly in immobile clients who may have difficulty maintaining moisture in their oral mucosa. This action helps promote comfort and prevent complications such as lip fissures and discomfort during oral care. Therefore, it is an appropriate action for the nurse to take.
B. Use the thumb and index finger to keep the client's mouth open: Forcing the client's mouth open with the thumb and index finger can be uncomfortable and may cause injury. Gentle techniques should be employed to maintain the client's mouth open if necessary, such as using a mouth prop or asking the client to open their mouth voluntarily.
C. Turn the client on his side before starting oral care: Turning the client on their side is an essential safety measure, particularly for immobile clients, to prevent aspiration and facilitate drainage of oral secretions during oral care. This position helps ensure that any excess fluid or debris can drain out of the mouth rather than pooling in the back of the throat, reducing the risk of aspiration pneumonia. Therefore, it is an appropriate action for the nurse to take.
D. Use a stiff toothbrush to clean the client's teeth: Using a stiff toothbrush can cause injury to the client's gums and oral tissues, especially if the client is immobile or has delicate oral tissues due to medical conditions or treatments. A soft-bristled toothbrush or sponge applicator should be used for oral care to avoid trauma and ensure thorough but gentle cleaning.

A. Cleanse the skin prior to procedure B. Apply the medication an hour before the procedure begins C. Use a visual pain rating scale to evaluate effectiveness of the treatment D. Apply to intact skin E. Spread the cream over the lateral surface of both forearms

Correct Answer is ["A","B","C","D"]

Explanation

A. Cleanse the skin prior to the procedure: Cleansing the skin before applying the transdermal analgesic cream is essential to remove any dirt, oils, or contaminants that could interfere with its absorption. This step helps ensure optimal drug delivery and effectiveness.
B. Apply the medication an hour before the procedure begins: Applying the transdermal analgesic cream an hour before the procedure allows sufficient time for the medication to be absorbed through the skin and reach its therapeutic effect. This timing ensures that the analgesic properties are in place when the IV insertion procedure starts.
C. Use a visual pain rating scale to evaluate the effectiveness of the treatment: Using a visual pain rating scale can help assess the child's pain level before and after applying the transdermal analgesic cream. This evaluation provides valuable feedback on the cream's effectiveness in providing pain relief.
D. Apply to intact skin: Transdermal medications are designed to be absorbed through intact skin. Applying the cream to intact skin ensures proper absorption and effectiveness of the analgesic medication.
E. Spread the cream over the lateral surface of both forearms. This option might not be necessary or appropriate for the intended purpose. The choice of application site for transdermal analgesic cream depends on the specific medication and the area of pain. While the lateral surface of the forearms can be a suitable site, it may not always be necessary or feasible to apply the cream to both forearms, especially if the intended IV insertion site is on one arm.

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A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing oral care for a client who is immobile. Which of the following actions should the nurse take?

Correct Answer is ["A","C"]

Explanation

A nurse is planning to apply a transdermal analgesic cream prior to inserting an IV for a preschool-age child. Which of the following actions should the nurse plan to take? (Select all that apply)

Correct Answer is ["A","B","C","D"]

Explanation

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