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 C

Explanation

Choice A rationale

Placing the client in a prone position is contraindicated during nasogastric tube insertion. This position does not facilitate the passage of the tube into the esophagus and can increase the risk of aspiration if the client were to vomit. The optimal position is high Fowler's, which utilizes gravity to aid tube advancement.

Choice B rationale

Measuring the nasogastric tube from the tip of the nose to the earlobe to the xiphoid process is the correct technique to estimate the length of the tube needed to reach the stomach. This method accounts for the distance from the nasal passage, down the pharynx and esophagus, to the stomach.

Choice C rationale

Instructing the client to place their chin to their chest and swallow helps to close the epiglottis, thereby preventing the nasogastric tube from entering the trachea and directing it towards the esophagus. Swallowing facilitates the downward movement of the tube with esophageal peristalsis.

Choice D rationale

Advancing the nasogastric tube quickly increases the client's discomfort and anxiety and elevates the risk of trauma to the nasal passages, pharynx, and esophagus. The tube should be advanced slowly and gently, allowing the client to swallow and cooperate during the procedure.

A. Green leafy vegetables. B. Citrus fruits and juices. C. White bread, rice, and potatoes. D. Nuts, turkey breast, and lean meats.

Correct Answer is D

Explanation

Choice A rationale

Green leafy vegetables are excellent sources of vitamins, minerals, and fiber, which are crucial for overall health during breastfeeding. However, they are not primary sources of complete protein, which contains all nine essential amino acids needed for milk production and maternal tissue repair.

Choice B rationale

Citrus fruits and juices are rich in vitamin C and provide hydration, which are important during breastfeeding. However, they are primarily sources of carbohydrates and micronutrients and do not offer significant amounts of protein necessary for increased protein intake during lactation.

Choice C rationale

White bread, rice, and potatoes are primarily sources of carbohydrates, providing energy. While they contribute to the overall caloric intake needed during breastfeeding, they are low in protein and do not offer the essential amino acids required in higher amounts for milk production and maternal needs.

Choice D rationale

Nuts, turkey breast, and lean meats are excellent sources of complete protein, providing all the essential amino acids required by a breastfeeding mother and her infant. These foods support milk production, tissue repair, and overall nutritional needs during lactation, making them healthy choices for increasing protein intake.

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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?