54. A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Inspection
Deep palpation
Auscultation
Light palpation
The Correct Answer is A,C,D,B
A. Inspection: Inspection is performed first to visually assess the abdomen for distention, discoloration, scars, or asymmetry. This noninvasive step provides baseline information before any manipulation that could alter bowel sounds or abdominal appearance.
C. Auscultation: Auscultation is performed next to evaluate bowel sounds and vascular sounds. Performing auscultation before palpation is critical because palpation can stimulate bowel activity, potentially producing misleading findings.
D. Light palpation: Light palpation follows auscultation to assess superficial tenderness, muscle tone, and any palpable masses. Gentle pressure minimizes discomfort and avoids altering deeper structures before initial assessment.
B. Deep palpation: Deep palpation is the final step to examine underlying organs and detect deeper masses or areas of tenderness. Performing it last ensures that prior inspection and auscultation are not affected by manipulation of the abdominal wall.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Massages the legs before applying the stockings: Massaging a leg with phlebitis can dislodge a thrombus and lead to a potentially life-threatening pulmonary embolism. Leg massage is contraindicated in clients at risk for deep vein thrombosis or with active venous inflammation.
B. Positions the client in a chair before applying the stockings: Applying elastic stockings while the client is seated can allow gravity to increase venous pressure, making application more difficult and potentially reducing effectiveness. This positioning is not recommended for safety or optimal fit.
C. Rolls the extra stocking material down to the client's knee: Rolling or folding the stockings creates constrictive bands that can impede circulation, increasing the risk of venous stasis or skin injury. Stockings should be applied smoothly without folds or wrinkles.
D. Elevates the legs before applying the stockings: Elevating the legs allows gravity to assist venous return, reduces edema, and facilitates proper application of elastic stockings. This technique ensures even pressure distribution and supports the prevention of thrombus formation.
Correct Answer is C
Explanation
A. One fingerbreadth of space between the cast and the skin: Adequate spacing indicates proper cast fit and helps prevent pressure sores, but it does not signal an immediate threat to circulation or tissue viability.
B. Ecchymosis on the inner left thigh: Mild bruising can occur from initial injury or cast application. While it should be monitored, it is not as urgent as compromised blood flow.
C. Diminished pulses on the affected extremity: Weak or absent pulses indicate impaired arterial circulation, which can lead to ischemia, tissue necrosis, or compartment syndrome. This finding requires immediate assessment and intervention to prevent permanent injury.
D. Client report of muscle spasms of the left leg: Muscle spasms can be uncomfortable but are typically not life- or limb-threatening. They are addressed after ensuring adequate circulation and neurovascular status.
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