How it Works
Try Naxlex NCLEX-RN (Free-Trial)

The nurse is preparing to examine a patient complaining of right lower quadrant (RLQ) pain.
Which technique is correct during the assessment? The nurse should:

A.

Avoid palpating the tender areas.

B.

Examine the tender area first.

C.

Palpate the tender area first and then auscultate for bowel sounds.

D.

Examine the tender area last.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Avoiding palpation of tender areas completely would be an incomplete assessment. While direct, forceful palpation of an acutely tender area should be approached cautiously, it is essential to gently assess the area's boundaries, consistency, and the presence of rebound tenderness or guarding to gather crucial diagnostic information.

Choice B rationale

Examining the tender area first in an abdominal assessment can cause significant pain and muscle guarding, making it difficult to assess other quadrants effectively and potentially skewing the assessment findings. This approach can also reduce patient cooperation for the remainder of the examination.

Choice C rationale

Auscultation for bowel sounds typically precedes palpation in an abdominal assessment because palpation can alter bowel motility and therefore the character of bowel sounds. While palpating the tender area last is correct, performing auscultation after palpation would introduce an artifact.

Choice D rationale

Examining the tender area last is the correct technique during an abdominal assessment. This approach minimizes patient discomfort, allows for a more thorough and accurate assessment of the non-tender areas first, and helps to establish rapport before eliciting potential pain, thereby ensuring a more reliable and complete examination.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is ["167"]

Explanation

Step 1 is: Calculate the flow rate in mL per hour. (500 mg ÷ 500 mg) × 250 mL = 250 mL. (250 mL ÷ 90 min) × 60 min = 166.666. mL/hr. Rounded to the whole number, the flow rate is 167 mL/hr.

Correct Answer is ["0.5"]

Explanation

Step 1: The order is 10,000 units.

Step 2: The available concentration is 20,000 units per 1 mL.

Step 3: Calculate the volume to administer: 10,000 units ÷ (20,000 units ÷ 1 mL) = 0.5 mL. Answer: 0.5 mL.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Register