Which action should the practical nurse (PN) implement when performing a focused assessment?
Wear clean gloves during auscultation of a client's heart sounds, lung sounds, and bowel sounds.
Dispose of gastric residual volume obtained when aspirating a client's nasogastric tube.
Weigh a mother holding her infant then subtract the mother's weight to obtain the infant's weight.
Place the blood pressure cuff on the thigh of a client with burns to the upper extremities.
The Correct Answer is B
A. Wear clean gloves during auscultation of a client's heart sounds, lung sounds, and bowel sounds. Gloves not required for auscultation unless contact with body fluids is anticipated.
B. Dispose of gastric residual volume obtained when aspirating a client's nasogastric tube: Standard practice unless facility policy specifies reinsertion; prevents aspiration risk.
C. Weigh mother holding infant then subtract the mother's weight to obtain the infant's weight: Not part of a focused assessment but a measurement technique.
D. Place BP cuff on thigh of a client with burns to the upper extremities: Adaptation for burn injuries but not related to general focused assessment steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Continue to auscultate the abdomen for a longer time period: Absence of bowel sounds should be confirmed after listening for 5 minutes in each quadrant before reporting.
B. Determine if client needs to empty bladder: Not related to bowel sounds.
C. Ask client to flex knees to relax the abdomen.: May relax abdomen but does not confirm bowel activity.
D. Notify charge nurse of the absence of bowel sounds: Only after confirming prolonged absence.
Correct Answer is A
Explanation
A. Report findings to supervisor for referral to APS: Mandatory reporting protects client safety.
B. Ask daughter who has been caring for client: May alert potential abuser and place client at further risk.
C. Apply dry dressings after cleansing wounds: Necessary, but safety and reporting take precedence.
D. Document the lacerations: Must be done, but immediate action is reporting.
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