The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

"We need to determine the areas of tenderness before using percussion and palpation."

"Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination."

"Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation."

"Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

Answer and Explanation

The Correct Answer is C

A. Determine areas of tenderness: While identifying tenderness is important, it is not the reason for auscultating first.

B. Allows the patient to relax: Relaxation is helpful but not the primary reason for the sequence.

C. Prevents distortion of bowel sounds: Percussion and palpation can stimulate or suppress bowel sounds, leading to inaccurate findings if performed before auscultation.

D. Prevents distortion of vascular sounds: Vascular sounds (bruits) are less likely to be affected by percussion or palpation.

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Correct Answer is B

Explanation

A. Pretibial edema: Edema is more indicative of venous function, not arterial function.

B. Palpate pedal pulses bilaterally: Palpation of the pedal pulses is essential to assess arterial circulation in the lower extremities.

C. Allen test: This assesses arterial blood flow to the hand, not the lower extremities.

D. Homan sign: Homan sign is used (though controversial) to assess for deep vein thrombosis (DVT), which is related to venous, not arterial, function.

A. Make note of this finding for the report to the next shift B. Prepare to remove cerumen from the patient's ear. C. Irrigate the ear with rubbing alcohol. D. Notify the patient's health care provider

Correct Answer is D

Explanation

A. Make note of this finding: Delaying action by merely reporting the finding later may compromise patient care.

B. Prepare to remove cerumen: Sudden hearing loss is unlikely to be caused by cerumen buildup without further assessment.

C. Irrigate with rubbing alcohol: This is inappropriate and could harm the ear.

D. Notify the health care provider: Sudden sensorineural hearing loss can be a medical emergency and should be promptly evaluated by the healthcare provider.

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The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following should the nurse perform to assess the arterial function of the lower extremities?

Correct Answer is B

Explanation

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what the matter is. All of a sudden, I can't hear you out of my left ear!" What should the nurse do next?

Correct Answer is D

Explanation

During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test?

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

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When assessing the pupillary light reflex or PERRL (pupils, round, reactive to light), the nurse should use which technique?

The nurse is testing a patient's visual accommodation, which refers to which action?

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?