The nurse is preparing to examine a patient who has been reporting right lower quadrant (RLQ) pain.
Which technique is correct during the assessment?

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

Examine the tender area last.

Examine the tender area first.

Avoid palpating the tender area altogether.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Palpating the tender area first can cause increased pain and muscle guarding, potentially interfering with the subsequent auscultation of bowel sounds. It is important to auscultate before palpation to avoid altering the natural bowel sounds.

Choice B rationale

Examining the tender area last minimizes the client's discomfort and reduces the likelihood of muscle guarding affecting the assessment of other abdominal areas. This systematic approach allows for a more accurate evaluation of non-tender regions before focusing on the area of complaint.

Choice C rationale

Examining the tender area first will likely cause the patient increased discomfort, leading to muscle guarding that can make it difficult to accurately assess other areas of the abdomen. This approach can also make the patient apprehensive and less cooperative for the remainder of the examination.

Choice D rationale

Avoiding palpation of the tender area altogether would result in an incomplete assessment. Palpation is crucial for evaluating tenderness, masses, and organomegaly in the area of the patient's pain. Modifying the order of assessment is preferred over complete avoidance.

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Correct Answer is B

Explanation

Choice A rationale

Canned tuna and salmon, while sources of protein and omega-3 fatty acids, are not particularly high in potassium. Clients taking potassium-wasting diuretics need foods rich in potassium to replace the electrolytes lost through increased urination.

Choice B rationale

Oranges and bananas are excellent sources of potassium. Potassium is an essential electrolyte that is often depleted by potassium-wasting diuretics like furosemide or hydrochlorothiazide. Consuming these fruits helps maintain adequate potassium levels, which are crucial for cardiac function and muscle contraction. The normal range for serum potassium is typically 3.5-5.0 mEq/L.

Choice C rationale

Dried fruits, such as apricots and raisins, are high in potassium. However, the question asks what the nurse *should* include, and while dried fruits are beneficial, fresh fruits like oranges and bananas are often more readily available and consumed in larger quantities.

Choice D rationale

Cow's milk contains potassium but is not specifically emphasized for clients on potassium-wasting diuretics. Other food sources like fruits and vegetables generally provide a more direct and often higher concentration of potassium without the added phosphorus and calcium found in milk, which may be considerations for some individuals.

A. 6 months. B. 8 months. C. 10 months. D. 12 months.

Correct Answer is D

Explanation

Choice A rationale

Introducing whole milk at 6 months is generally too early. At this age, an infant's primary nutrition should still come from breast milk or formula, which are specifically formulated to meet their developmental needs. The infant's digestive system is still maturing and may not be fully ready to process the higher protein and fat content of whole cow's milk.

Choice B rationale

Transitioning to whole milk at 8 months is also typically premature. While some infants might show readiness signs earlier, the American Academy of Pediatrics recommends waiting until closer to 12 months. Introducing whole milk too soon can displace the intake of breast milk or formula, potentially leading to deficiencies in essential nutrients like iron.

Choice C rationale

Waiting until 10 months is closer to the recommended timeframe, but most guidelines still advise waiting until 12 months. This allows the infant's digestive system more time to mature and ensures they receive optimal nutrition from breast milk or formula for a longer duration. Early introduction of whole milk doesn't offer any significant nutritional advantages over breast milk or formula during this period.

Choice D rationale

The American Academy of Pediatrics recommends transitioning to whole cow's milk around 12 months of age for most infants. By this time, their digestive system is more mature and capable of handling the nutrients in whole milk. Additionally, most infants at this age are consuming a wider variety of solid foods, which helps ensure they are meeting their nutritional needs beyond just milk.

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The nurse is preparing to examine a patient who has been reporting right lower quadrant (RLQ) pain.Which technique is correct during the assessment?

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The nurse is preparing to examine a patient who has been reporting right lower quadrant (RLQ) pain.Which technique is correct during the assessment?

The nurse is preparing to examine a patient who has been reporting right lower quadrant (RLQ) pain.
Which technique is correct during the assessment?