A charge nurse is preparing to observe a newly licensed nurse perform a routine abdominal assessment. Which of the following actions should the charge nurse expect the newly licensed nurse to take?
Place the client in a dorsal recumbent position for the examination.
Auscultate for vascular bruits with the diaphragm of the stethoscope.
Begin the assessment by using light palpation over the abdomen.
Ensure that the client has a full bladder before beginning the procedure.
The Correct Answer is A
The correct answer is Choice A: Place the client in a dorsal recumbent position for the examination.
Choice A rationale:
The dorsal recumbent position, where the client lies on their back with knees bent and feet flat on the bed, is ideal for abdominal assessments. This position helps relax the abdominal muscles, making it easier to palpate and auscultate the abdomen.
Choice B rationale:
Auscultating for vascular bruits should be done with the bell of the stethoscope, not the diaphragm. The bell is more sensitive to low-frequency sounds like bruits.
Choice C rationale:
The assessment should begin with inspection and auscultation before palpation. Palpation can alter bowel sounds, leading to inaccurate findings.
Choice D rationale:
The client should have an empty bladder before the assessment to avoid discomfort and ensure accurate findings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice c. Pick up the first sterile glove by grasping the folded cuff edge.
Choice A rationale:
Opening the top flap of the sterile package towards the body is incorrect. The top flap should be opened away from the body to maintain sterility and prevent contamination.
Choice B rationale:
Maintaining a 1.25 cm (0.5 in) border around the edges of the sterile field is correct practice, but it is not the specific action being asked about in this scenario.
Choice C rationale:
Picking up the first sterile glove by grasping the folded cuff edge is correct. This technique ensures that the outside of the glove remains sterile while putting it on.
Choice D rationale:
Removing soiled dressings using sterile gloves is incorrect. Soiled dressings should be removed using clean gloves to avoid contaminating the sterile gloves needed for the new dressing application.
Correct Answer is C
Explanation
Choice A rationale:
Assigning clients who have had stem cell transplants to the same room is not a recommended practice. Clients with compromised immune systems should be isolated to reduce the risk of infection transmission. Placing them together increases the potential for exposure to infectious agents.
Choice B rationale:
Obtaining a rectal temperature on clients every 4 hours is not specifically related to caring for clients following stem cell transplants. Vital sign monitoring is essential, but the frequency and method of temperature measurement can vary based on the individual client's condition and clinical judgment.
Choice C rationale:
(Correct Choice) Wearing an N95 respirator mask while caring for clients following stem cell transplants is important due to their compromised immune systems. These clients are at higher risk of infections, and N95 masks provide enhanced respiratory protection against airborne pathogens.
Choice D rationale:
Placing clients in positive-pressure airflow rooms is not a standard practice for caring for clients following stem cell transplants. Positive-pressure rooms are often used for clients with conditions like immunodeficiency, but stem cell transplant recipients are generally placed in protective isolation rooms to minimize infection risk.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.