A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment.

(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

Inspect the abdomen for skin integrity.

Ask the client about having a history of abdominal pain.

Auscultate the abdomen for bowel sounds.

Percuss the abdomen in each of the four quadrants.

Palpate the abdomen gently for tenderness.

Answer and Explanation

The Correct Answer is A,B,C,D,E

1.   a) Inspect the abdomen for skin integrity: The first step in an abdominal assessment is inspection. The nurse should visually examine the abdomen for any abnormalities such as skin changes, scars, distention, or masses.
2.   b) Ask the client about having a history of abdominal pain: Gathering a history of abdominal pain is crucial as it provides context for the physical findings. This step helps identify any underlying conditions that may influence the assessment.
3.   c) Auscultate the abdomen for bowel sounds: Auscultation should be performed before palpation and percussion to avoid altering the bowel sounds. The nurse listens for the presence, frequency, and character of bowel sounds in all four quadrants.
4.   d) Percuss the abdomen in each of the four quadrants: Percussion helps to assess the presence of fluid, air, or masses in the abdomen. The nurse taps on the abdomen to listen for sounds that indicate the underlying structures.
5.   e) Palpate the abdomen gently for tenderness: Palpation is the final step and involves gently pressing on the abdomen to check for tenderness, masses, or organ enlargement. This step should be done last to avoid causing discomfort or altering the findings of the other steps.

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Correct Answer is ["100"]

Explanation

Step 1: Identify the infusion rate in mL/hr.

The infusion rate is 100 mL/hr.
= 100 mL/hr.

Step 2: Determine the drop factor for microtubing.

Microtubing has a drop factor of 60 gtt/mL.
= 60 gtt/mL.

Step 3: Calculate the drip rate in gtt/min.

Drip rate (gtt/min) = (Infusion rate in mL/hr) × (Drop factor in gtt/mL) ÷ 60.
Drip rate (gtt/min) = 100 mL/hr × 60 gtt/mL ÷ 60.
= 100 gtt/min.

So, the nurse should set the manual IV infusion to deliver 100 gtt/min.

Correct Answer is ["2"]

Explanation

Step 1: Determine the dosage required. Required dosage = 150 mg

Step 2: Determine the dosage available per tablet. Available dosage per tablet = 75 mg

Step 3: Calculate the number of tablets needed. Number of tablets needed = Required dosage ÷ Available dosage per tablet Number of tablets needed = 150 mg ÷ 75 mg

Step 4: Perform the division. 150 ÷ 75 = 2

The nurse should administer 2 tablets per dose.

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

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)

Correct Answer is ["100"]

Explanation

A nurse is preparing to administer amitriptyline 150 mg PO at bedtime. The amount available is amitriptyline 75 mg tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["2"]

Explanation

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A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment.

(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)