A nurse performs an abdominal assessment on 4 patients. Which of the following would be considered a normal abdominal assessment?
Abdomen nondistended, soft, with active bowel sounds in all four quadrants.
Abdomen distended, firm, with hypoactive bowel sounds in all four quadrants.
Abdomen distended, soft, with hyperactive bowel sounds in all four quadrants.
Abdomen nondistended, firm, with hypoactive bowel sounds in all four quadrants.
The Correct Answer is A
Choice A This is considered a normal abdominal assessment. The abdomen is soft and not distended, and bowel sounds are present and normal in all four quadrants.
Choice B Abdominal distension and firmness may indicate possible bowel obstruction or other gastrointestinal issues. Hypoactive bowel sounds suggest reduced motility, which is not normal.
Choice C Abdominal distension with hyperactive bowel sounds may indicate gastrointestinal irritation or increased motility, which is not normal.
Choice D A firm abdomen with hypoactive bowel sounds is not typical of a normal abdominal assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Alcohol swabs may be too harsh and irritating for the delicate skin around the stoma. Mild soap and water are preferred for cleaning.
Choice B Tap water alone may not be sufficient for removing debris and ensuring proper cleanliness around the stoma. Mild soap and water are preferred for cleaning.
Choice C Iodine may be too harsh and irritating for the peristomal skin. Mild soap and water are preferred for cleaning.
Choice D Mild soap and water are the best choice for cleaning around the colostomy stoma as they effectively remove debris and cleanse the area without being overly harsh on the skin.
Correct Answer is B
Explanation
The correct answer is Choice B.
Choice A rationale: Waiting until the ostomy drainage bag is full increases the risk of leakage and can put undue pressure on the stoma, leading to potential skin irritation or damage. Regular emptying is crucial for maintaining stoma health and preventing complications.
Choice B rationale: Emptying the ostomy drainage bag when it is 1/2 full is recommended to prevent leaks and reduce pressure on the stoma. This practice helps maintain skin integrity around the stoma and ensures the drainage bag functions effectively.
Choice C rationale: Emptying the ostomy drainage bag when it is only 1/4 full may be too frequent and unnecessary, leading to increased use of supplies and potential irritation from frequent manipulation. It is more practical to aim for 1/2 full for routine care.
Choice D rationale: Waiting until the ostomy drainage bag is 3/4 full increases the risk of leakage and pressure on the stoma, similar to waiting until it is full. It is essential to empty the bag more regularly to maintain optimal stoma health and prevent issues
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