The patient complains of abdominal pain. Before palpating the abdomen, which action should the nurse perform?
Don sterile gloves.
Elevate the patient’s head.
Percuss all four quandrants.
Auscultate the bowel sounds.
The Correct Answer is D
Choice A reason: Donning sterile gloves is unnecessary for abdominal assessment, as it requires clean gloves to prevent infection. Sterile gloves are used for invasive procedures, not palpation or auscultation. This action is irrelevant to preparing for palpation and wastes resources, per infection control and assessment protocols.
Choice B reason: Elevating the patient’s head may relax abdominal muscles but is not required before palpation. Auscultation precedes palpation to avoid altering bowel sounds by pressure. Elevating the head does not address the need for accurate bowel sound assessment, making it less critical, per abdominal examination sequence.
Choice C reason: Percussing all four quadrants follows auscultation and inspection, not precedes palpation. Percussion assesses organ size or fluid but may disrupt bowel sounds if done before auscultation. Auscultation is prioritized to capture unaltered sounds, ensuring a systematic abdominal assessment, per clinical examination guidelines.
Choice D reason: Auscultating bowel sounds before palpation is essential, as palpation may alter peristalsis, leading to inaccurate findings. Listening for hypoactive or hyperactive sounds identifies abnormalities like obstruction, guiding further assessment. This sequence preserves diagnostic accuracy, aligning with systematic abdominal examination protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Labeling the action as libel, a felony, is incorrect, as libel involves defamatory statements, not clinical errors. Negligence relates to failing to meet care standards, not legal defamation. This mischaracterizes the issue, focusing on legal terms irrelevant to the failure to report critical hypertension, per nursing liability.
Choice B reason: While poor interprofessional communication may have contributed, it does not fully capture the negligence. The primary issue is not reporting a critical blood pressure (202/122), which a prudent nurse would address. Communication is secondary to the nurse’s failure to act on a life-threatening finding, per professional standards.
Choice C reason: Failing to act as a prudent nurse under similar circumstances defines negligence, as not reporting 202/122 mmHg endangered the patient, leading to ICU transfer. A reasonable nurse would have notified the provider, preventing harm, aligning with legal and ethical standards of care and accountability.
Choice D reason: Not reassessing blood pressure is relevant but not the core negligence. The primary issue is failing to report the critical reading, which required immediate action. Reassessment alone would not address the urgency of notifying the provider, making this less comprehensive than negligence, per standards.
Correct Answer is A
Explanation
Choice A reason: Crackles indicate fluid or mucus in alveoli, often from pneumonia or pulmonary edema. Deep breathing and coughing mobilize secretions, potentially clearing airways. Repeating auscultation assesses if crackles persist, guiding diagnosis. This intervention enhances gas exchange by clearing alveoli, reducing hypoxia risk, and is the first step before escalating care.
Choice B reason: Limiting fluid intake to less than 2,000 mL/day is inappropriate without a diagnosis like heart failure. Crackles suggest alveolar fluid, but restricting fluids could worsen dehydration in infections like pneumonia. Deep breathing and coughing are prioritized to clear airways, improving oxygenation, while fluid restriction requires medical evaluation of underlying causes.
Choice C reason: Preparing antibiotics assumes a bacterial infection, but crackles may stem from non-infectious causes like pulmonary edema. Antibiotics target bacterial cell walls but are premature without confirmed infection. Repeating auscultation after coughing assesses airway clearance, guiding whether further diagnostic tests or treatments, like antibiotics, are needed based on findings.
Choice D reason: Semi-Fowler’s position aids breathing but does not address crackles directly. Crackles indicate fluid or mucus obstructing alveoli, impairing gas exchange. Deep breathing and coughing mobilize secretions, potentially resolving crackles, while positioning is a supportive measure. Repeating auscultation after coughing is the priority to assess airway clearance and guide interventions.
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