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
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Report the injury to a nurse manager:
While reporting the incident is important, the immediate action to take is cleaning the affected area to minimize the risk of infection.
B. Wash the affected area with soap and water:
This is the immediate priority to reduce the risk of potential infection or transmission of any contaminants from the needlestick injury.
C. Report the needle stick to the infection control department:
Reporting the incident is essential, but it should follow the immediate step of cleaning the affected area to prevent infection.
D. Scrub the area with hand sanitizer for a full 2 minutes:
Hand sanitizer may not be as effective as soap and water in removing contaminants from a needlestick injury site. Washing with soap and water is more appropriate for cleaning the area.
Correct Answer is A
Explanation
A. Use standard precautions in caring for all clients:
Standard precautions involve applying infection prevention practices to all clients, regardless of their known or suspected infectious status. This includes hand hygiene, use of personal protective equipment (PPE), and safe injection practices. Standard precautions are designed to prevent the transmission of microorganisms and break the chain of infection.
B. Place all post-surgical clients in contact isolation:
Contact isolation is typically used for clients with known or suspected infections that can be spread through direct or indirect contact. Placing all post-surgical clients in contact isolation may not be necessary unless there is evidence of a specific infectious condition.
C. Order IV antibiotics for all clients with sacral pressure wounds:
Ordering antibiotics is a specific treatment for bacterial infections but does not address the broader approach of breaking the chain of infection for all clients.
D. Limit visitations to 2 people a day for each client:
While limiting visitations can reduce the risk of introducing infections, it does not address the nurse's direct care practices and adherence to infection prevention measures.
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