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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The side-lying position with the head of bed at 30 degrees does not optimally align the nasal passages with the esophagus, increasing the risk of the NGT entering the trachea. Proper alignment facilitates easier and safer insertion into the stomach.
Choice B rationale
The tripod position is typically used for patients experiencing respiratory distress to maximize lung expansion. It does not provide the necessary head and neck alignment for safe nasogastric tube insertion.
Choice C rationale
Sitting the patient in an upright position, ideally between 45 to 90 degrees, uses gravity to aid the passage of the NGT down the esophagus. This position also allows the patient to cough effectively if the tube inadvertently enters the trachea.
Choice D rationale
Hyperextending the patient's head during NGT insertion can close off the esophagus and open the trachea, significantly increasing the risk of misplacement of the tube into the respiratory tract. The neck should be flexed forward with the chin to the chest during insertion.
Correct Answer is D
Explanation
Choice A rationale
NPO (nothing by mouth) might be a temporary measure immediately following a stroke if aspiration risk is very high. However, prolonged NPO can lead to malnutrition and dehydration, hindering recovery. Nutritional support is crucial for stroke patients, so alternative feeding methods should be explored.
Choice B rationale
Total parenteral nutrition (TPN) is a method of providing nutrients intravenously, bypassing the gastrointestinal tract. It is usually reserved for patients with severe gastrointestinal dysfunction or when enteral feeding is not feasible or tolerated. While it provides nutrition, it carries risks of infection and metabolic complications and is not the first-line treatment for dysphagia.
Choice C rationale
A mechanical soft diet consists of foods that are easy to chew and swallow, reducing the risk of choking and aspiration in patients with mild to moderate dysphagia. This diet provides necessary nutrients while minimizing the effort required for safe oral intake, promoting better nutrition and hydration compared to NPO.
Choice D rationale
Supplements via NG tube provide enteral nutrition directly into the stomach or small intestine, bypassing the oral cavity and pharynx. This is an appropriate nutritional therapy for patients with severe dysphagia who cannot safely swallow even modified textures, ensuring adequate caloric and nutrient intake to support recovery and prevent malnutrition.
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