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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pallor and cyanosis: Indicative of arterial insufficiency, not venous disease.
B. Thin, shiny skin: Seen in peripheral arterial disease (PAD).
C. Brownish discoloration: Caused by hemosiderin deposits from chronic venous congestion.
D. Unilateral cool foot: Suggests acute arterial obstruction.
Correct Answer is A
Explanation
A. A vision of 20/30 means that the patient can read at 20 feet what a person with normal vision can read at 30 feet, indicating mild visual impairment.
B. This reverses the explanation of 20/30 vision and is incorrect.
C. This option incorrectly describes the Snellen chart results, which measure clarity of vision at specific distances, not entire chart reading ability.
D. This option confuses visual acuity for each eye; Snellen scores do not indicate different distances for each eye.
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