Complete the following sentence using the list of options.
When performing a physical assessment, the first technique the nurse will always use is?
Inspection.
Auscultation.
Percussion.
Palpation.
The Correct Answer is A
Choice A rationale
Inspection is the systematic observation of the patient using the senses of sight, smell, and hearing. It is always the first technique used in a physical assessment because it provides a foundational understanding of the patient's general appearance, symmetry, posture, skin condition, and any visible abnormalities before physical contact is made.
Choice B rationale
Auscultation involves listening to sounds produced by the body, such as heart sounds, lung sounds, and bowel sounds, using a stethoscope. While crucial for assessing various body systems, it typically follows inspection and palpation to avoid altering natural body sounds.
Choice C rationale
Percussion involves tapping on body surfaces to elicit sounds that indicate the density of underlying tissues and organs. This technique helps in assessing organ size, shape, and consistency, but it is performed after inspection and palpation, as it involves direct contact and manipulation.
Choice D rationale
Palpation involves using the sense of touch to assess characteristics such as texture, temperature, moisture, organ size and location, and tenderness. While a vital component of the physical assessment, it follows inspection to avoid introducing discomfort or altering initial observations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Using a large bore needle (e.g., 18-gauge) for withdrawing medication from an ampule is generally avoided unless the medication is highly viscous, because it can create a larger hole in the ampule, increasing the risk of glass particle introduction. The primary concern with ampules is preventing glass shards from entering the syringe, which is addressed by filtration, not needle bore size alone.
Choice B rationale
Ampules are single-dose glass containers. When an ampule is opened, small, invisible glass fragments can break off. A filter needle contains a microscopic filter that traps these glass particles, preventing their aspiration into the syringe and subsequent injection into the patient, thus mitigating the risk of phlebitis, emboli, or other complications from particulate matter.
Choice C rationale
A small gauge needle (e.g., 25-gauge) has a very narrow lumen, which would make withdrawing medication from an ampule unnecessarily difficult and slow, especially for viscous solutions. Furthermore, a small gauge needle does not mitigate the risk of glass particle aspiration, which is the paramount concern when withdrawing medication from a glass ampule.
Choice D rationale
Placing a cotton ball over the opening of an ampule is not a scientifically sound method to prevent being cut or to prevent glass shards from entering the medication. Ampules are designed to be broken cleanly. Proper ampule opening techniques and the use of a filter needle are the established safety measures to prevent injury and contamination.
Correct Answer is B
Explanation
Choice A rationale
Assessing the client's skin for breakdown is important in general patient care, especially for immobile patients, but it is not a priority assessment directly related to the immediate physiological effects of administering an opioid analgesic like morphine. Skin integrity issues are typically a long-term complication.
Choice B rationale
Morphine, an opioid agonist, binds to mu-opioid receptors in the central nervous system, including the brainstem respiratory centers. This binding causes dose-dependent respiratory depression by decreasing the sensitivity of these centers to carbon dioxide, leading to reduced respiratory rate and depth. Normal respiratory rate is 12-20 breaths/min.
Choice C rationale
Opioids can cause urinary retention by increasing bladder sphincter tone and reducing detrusor muscle contractility, thereby impairing bladder emptying. While monitoring urinary output is important, respiratory depression is a more immediate and life-threatening adverse effect of opioid administration. Normal urinary output is 30-50 mL/hour.
Choice D rationale
Opioids commonly cause gastrointestinal side effects, including decreased gut motility, leading to constipation and reduced bowel sounds. While assessing abdominal sounds is relevant to monitor for ileus, respiratory depression poses a more acute and significant risk to patient safety following opioid administration.
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