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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
The ethics committee does not typically handle requests for access to medical records. Their role is more focused on addressing ethical dilemmas and conflicts in patient care, rather than routine administrative tasks like granting access to medical records.
Choice B reason:
Asking the nursing supervisor to obtain the medical records for a family member is not appropriate without the client’s consent. Medical records are confidential and protected under laws such as HIPAA (Health Insurance Portability and Accountability Act), which require patient authorization for disclosure.
Choice C reason:
The healthcare provider cannot share medical information with a family member without the client’s explicit permission. This is to ensure the privacy and confidentiality of the client’s health information.
Choice D reason:
The correct procedure is for the client to provide permission to share their medical records. Under HIPAA, a healthcare provider can only share a patient’s medical information with family members if the patient has given explicit consent. This ensures that the patient’s privacy rights are respected and that their health information is protected.
Correct Answer is B
Explanation
Choice A reason:
Turn the client every 4 hours: Regularly turning the client can help prevent pressure ulcers and improve overall circulation, but it is not the most effective measure specifically for preventing ventilator-associated pneumonia (VAP). While repositioning can help with lung expansion and secretion clearance, oral care is more directly related to reducing VAP risk.
Choice B reason:
Brush the client’s teeth with a suction toothbrush every 12 hours: Oral care is crucial in preventing VAP. Bacteria from the mouth can easily travel to the lungs, especially in intubated patients. Using a suction toothbrush helps remove dental plaque and secretions, reducing the bacterial load and the risk of infection. This practice is a key component of VAP prevention bundles.
Choice C reason:
Provide humidity by maintaining moisture within the ventilator tubing: While maintaining humidity is important to prevent drying of the respiratory mucosa and to help with secretion clearance, it does not directly reduce the risk of VAP. Proper humidification is necessary for patient comfort and respiratory function but is not a primary VAP prevention strategy.
Choice D reason:
Position the head of the client’s bed in the flat position: Positioning the head of the bed flat can increase the risk of aspiration, which is a significant risk factor for VAP. The head of the bed should be elevated to 30-45 degrees to reduce the risk of aspiration and promote better lung expansion.
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