The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)
Palpation.
Inspection.
Auscultation.
Percussion.
The Correct Answer is B
Inspection, followed by Auscultation, Percussion, and Palpation. Inspection assesses for abdominal contour, symmetry, any visible masses, scars or other abnormalities. Auscultation assesses bowel sounds, and Percussion assesses for any areas of tenderness, and to determine the presence of fluid, gas or masses. Palpation assesses for any masses, areas of tenderness, organ size or other abnormalities. This is the order that allows the nurse to assess the abdomen systematically and accurately.
A: Palpation comes last because it can stimulate bowel sounds, which can make the nurse miss some of the sounds while auscultating.
C: Auscultation must be done before percussion and palpation to prevent altering bowel sounds.
D: Percussion comes before palpation to avoid altering the underlying structures of the abdomen.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Schedule injection on a nondialysis day. Epoetin is a medication used to stimulate the production of red blood cells. It is important to administer the medication on the day that the client is not receiving dialysis to prevent the medication from being removed from the bloodstream during the dialysis process.
Administering epoetin immediately after dialysis, choice B may result in decreased effectiveness.
Administering with low-dose aspirin, choice A, is not a standard recommendation for the administration of epoetin.
Monitoring the complete blood count prior to the dose, choice C is not the most important consideration when administering epoetin.
Correct Answer is D
Explanation
Radiographic confirmation. Radiographic confirmation is the most reliable method to verify the placement of nasogastric tubes, and it is considered the gold standard. The nurse should use it to confirm placement initially and periodically to ensure that the tube is in the stomach and not in the lungs or esophagus.
Option A, placing the end of the tube in water and observing for bubbling, is incorrect because it is not a reliable method, and it can cause aspiration or infection.
Option B, using the auscultation technique, is incorrect because it can lead to misinterpretation of bowel sounds, and it is not reliable.
Option C, measuring pH of aspirates, is incorrect because it is not a reliable method, and it can be affected by several factors, including medications, stress, and nutritional status.
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