The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

inspection

percussion

palpation

auscultation

Answer and Explanation

The Correct Answer is A

A. Inspection: Inspection is always the first step in any physical examination, including abdominal assessments. It allows the nurse to visually assess the abdomen for distension, asymmetry, discoloration, or other abnormalities.

B. Percussion: Percussion is performed after inspection and auscultation. It helps assess the density of abdominal contents but should not be the first step.

C. Palpation: Palpation is performed last in an abdominal exam to avoid altering bowel sounds and causing discomfort. It should be done after inspection, auscultation, and percussion.

D. Auscultation: Auscultation is typically the second step after inspection to listen for bowel sounds before palpation and percussion, which might alter them.

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Correct Answer is B

Explanation

A. "Do you smoke?" This is a closed-ended question that can be answered with a simple "yes" or "no." It doesn't encourage elaboration or detailed responses.

B. "How are you feeling?" This is an open-ended question that encourages the client to provide more detailed and descriptive responses about their current state or feelings. It allows the client to share more information and gives the nurse a better understanding of their condition.

C. "Are you feeling well?" Similar to option A, this is a closed-ended question. It prompts a "yes" or "no" answer without inviting further discussion or detailed explanation.

D. "Do you use any illicit drugs?" This is another closed-ended question that requires a "yes" or "no" answer. It does not provide the opportunity for the client to discuss their drug use in detail.

A. Document "impaired oxygenation" on the nursing care plan. B. Auscultate the chest for breath sounds. C. Collaborate with the client to form goals. D. Apply supplemental oxygen by face mask as needed.

Correct Answer is B

Explanation

A. Document "impaired oxygenation" on the nursing care plan: While this may be appropriate based on assessment findings, it's premature to document without conducting a thorough assessment first.

B. Auscultate the chest for breath sounds: This is a critical component of assessing respiratory function, especially in a client with pneumonia, to identify abnormal breath sounds such as crackles or diminished breath sounds.

C. Collaborate with the client to form goals: Goal setting typically comes after assessment data is collected and analyzed.

D. Apply supplemental oxygen by face mask as needed: This action should be based on assessment findings indicating the need for oxygen therapy, not assumed without assessment.

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The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

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