The nurse is preparing to perform an abdominal examination. Which step would be taken first?
Auscultation
Inspection
Percussion
Palpation
The Correct Answer is B
Choice A rationale
Auscultation is an important step in an abdominal examination, but it is not the first step. It is performed after inspection and before percussion and palpation to ensure that the motility of the bowel and bowel sounds are not altered.
Choice B rationale
Inspection is the first step in an abdominal examination. This step involves visually examining the abdomen for any abnormalities, such as distension, discoloration, or visible peristalsis. The
nurse observes the color, shape, and movement of the abdomen, and looks for any visible masses, scars, or skin changes. This step provides valuable information about the patient’s overall health and potential issues that may require further investigation.
Choice C rationale
Percussion is a part of the abdominal examination, but it is not the first step. It is performed after inspection and auscultation. During percussion, the nurse taps on the abdomen to assess the size and position of the abdominal organs, and to detect any fluid or masses.
Choice D rationale
Palpation is the last step in an abdominal examination. It is performed after inspection, auscultation, and percussion. During palpation, the nurse uses their hands to feel the abdomen for any masses, tenderness, or organ enlargement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
After a Roux-en-Y surgical procedure, patients are typically put on a liquid-only diet for the first week or two after surgery. Over the next month, they are able to add soft food and eventually regular food back into their diet. Given that the patient is only one day postoperative, the consumption of solid foods like strawberry yogurt could potentially lead to
complications such as dumping syndrome, which is a group of symptoms that includes vomiting, nausea, and dizziness. It occurs when food moves from your stomach into your small intestine too quickly.
Choice B rationale
Chicken broth is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Choice C rationale
Apple juice is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Choice D rationale
Iced tea is a clear liquid and is generally considered safe for a patient who is one day postoperative from a Roux-en-Y surgical procedure. It is easily digestible and does not put undue stress on the digestive system.
Correct Answer is A
Explanation
Choice A rationale
Jaundice, a common symptom of cholecystitis, is a yellow discoloration of the skin and whites of the eyes (sclera) caused by an excess of bilirubin in the blood. The sclera is often the first place where jaundice is noticeable because the high amount of elastin in the sclera binds to bilirubin, causing a yellowish discoloration.
Choice B rationale
While nail beds can sometimes show signs of certain health issues, they are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice C rationale
The periumbilical area (around the belly button) is not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
Choice D rationale
The webbed areas of the fingers are not typically used to monitor for the presence of jaundice. Jaundice primarily causes yellowing of the skin and the whites of the eyes.
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