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

A.

Palpation

B.

The order does not matter

C.

Auscultation

D.

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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Related Questions

Correct Answer is D

Explanation

A. Placing the nurse's feet close together side by side to have a good center of gravity:

While maintaining a good center of gravity is important, in a falling situation, it's crucial to prioritize the client's safety over the nurse's stability. This option doesn’t address the prevention of the client’s fall.

B. Rocking the nurse's pelvis out and trying to hold the patient up to prevent falling:

Attempting to hold the patient up during a fall may put both the nurse and the client at risk of injury.

C. Grasping the gait belt and pushing the client’s body backward away from the nurse's body:

Pushing the client backward could cause the client to lose balance and fall in an uncontrolled manner.

D. Using the patient's gait belt to gently slide the client down the nurse's body to the floor:

This is the recommended action as it allows for a controlled descent to the floor, minimizing the impact of the fall and reducing the risk of injury to both the client and the nurse.

Correct Answer is C

Explanation

A. Pulse:

A pulse rate of 88 bpm is within the normal range. While it's important to monitor the pulse for changes, the reported pulse rate does not raise immediate concerns.

B. Temperature:

An oral temperature of 99.2 degrees Fahrenheit is within the normal range. While it's slightly elevated, it might be influenced by various factors, and isolated temperature readings are not as urgent as other vital signs.

C. Blood Pressure:

A blood pressure reading of 178/112 mm Hg is significantly elevated. High blood pressure is a major concern due to the potential risks it poses to the cardiovascular system, kidneys, and other organs. Immediate attention and further assessment are needed.

D. Respirations:

Respiratory rate of 18 bpm is within the normal range. While it's important to monitor respiratory rate, the reported rate does not raise immediate concerns.

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