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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Choice A reason:
Albuterol is primarily a bronchodilator and does not significantly reduce inflammation. Anti-inflammatory medications, such as corticosteroids, are typically used to address inflammation in the airways.
Choice B reason:
While albuterol can help reduce coughing episodes by opening the airways and making breathing easier, it is not its primary function. Coughing can be a symptom of bronchospasm, which albuterol helps to relieve.
Choice C reason:
Albuterol is effective in preventing wheezing by relaxing the muscles around the airways, which helps to open them up and allow more air to flow through. This action helps to alleviate wheezing, a common symptom of asthma and other respiratory conditions.
Choice D reason:
The primary function of albuterol is to open the airways. It is a bronchodilator that works by relaxing the smooth muscles around the airways, allowing them to widen and making it easier to breathe.
Choice E reason:
Albuterol does not stimulate the flow of mucus. Its main action is to relax the airway muscles and improve airflow. Mucus production is typically managed by other medications or treatments.
Correct Answer is ["2.0"]
Explanation
To calculate the dosage, follow these steps:
Step 1: Identify the prescribed dose.
The prescribed dose is 25 mg.
Result: 25 mg.
Step 2: Identify the concentration of the medication.
The concentration is 12.5 mg/mL.
Result: 12.5 mg/mL.
Step 3: Calculate the volume to administer.
Volume (mL) = (Prescribed dose in mg) ÷ (Concentration in mg/mL).
Volume (mL) = 25 mg ÷ 12.5 mg/mL.
Volume (mL) = 2 mL.
Result: 2 mL.
So, the nurse should administer 2.0 mL of diphenhydramine elixir per dose.
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