During a physical assessment a nurse inspects a patient’s abdomen. What assessment technique would the nurse perform next?

Palpation

The order does not matter

Auscultation

Percussion

Answer and Explanation

The Correct Answer is C

A. Palpation:

Palpation involves using the hands to feel for tenderness, masses, or abnormalities in the abdomen. It is typically performed after auscultation. This helps prevent stimulating bowel activity before listening to bowel sounds.

B. The order does not matter:

In the context of abdominal assessment, the order does matter. Following a specific sequence, such as inspection, auscultation, palpation, and then percussion, is recommended to ensure a comprehensive and accurate assessment.

C. Auscultation:

Auscultation involves listening to bowel sounds using a stethoscope. It is the next step after inspection. Listening to bowel sounds before palpation helps avoid artificially stimulating bowel activity.

D. Percussion:

Percussion involves tapping the abdomen to assess for the presence of fluid or air. While less commonly performed in routine abdominal assessments, it is usually the last technique after inspection, auscultation, and palpation.

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Correct Answer is C

Explanation

A. Droplet isolation:

Droplet isolation is used for diseases spread by respiratory droplets that are larger than those in airborne transmission. Examples include influenza and bacterial meningitis.

B. Enhanced contact isolation:

Enhanced contact precautions are implemented for patients known or suspected to be infected with pathogens that require additional control measures beyond standard precautions. This may include multi-drug resistant organisms.

C. Airborne isolation:

Airborne isolation is specifically used for diseases that are transmitted through small airborne particles that can remain suspended in the air for an extended period. Tuberculosis is one such example. The use of N95 respirators and negative pressure rooms is common for airborne precautions.

D. Neutropenic isolation:

Neutropenic precautions are implemented for patients with compromised immune systems, particularly those with low neutrophil counts. It involves measures to protect the patient from potential infections.

A. Every four hours. B. Every hour. C. Every shift. D. Every two hours

Correct Answer is D

Explanation

A. Every four hours:

Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.

B. Every hour:

Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.

C. Every shift:

Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.

D. Every two hours:

Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.

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During a physical assessment a nurse inspects a patient’s abdomen. What assessment technique would the nurse perform next?

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