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 ["A","C","D","E"]
Explanation
The correct answers are choices A, C, D, and E:
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Choice A rationale: The right to be treated with respect and dignity is a fundamental client right in any healthcare setting, including long-term care facilities. This right ensures that clients receive care in a compassionate and respectful manner.
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Choice B rationale: Full access to the facility is not a standard client right in long-term care facilities. Access to certain areas might be restricted for safety reasons or to maintain privacy.
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Choice C rationale: The right to refuse medications is an essential aspect of client autonomy, allowing clients to make informed decisions about their care. It is important to address this right during orientation.
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Choice D rationale: The right to leave regardless of provider recommendations is another aspect of client autonomy. Clients should be informed of their right to refuse care or leave the facility if they wish, even if it goes against the advice of healthcare providers.
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Choice E rationale: The right to be fully informed of their health conditions is a crucial aspect of client autonomy and transparency in healthcare. Clients should be aware of their health status and treatment options to make informed decisions about their care.
In conclusion, when conducting an orientation class for new clients and their families at a long-term care facility, the nurse should address the rights to be treated with respect and dignity, refuse medications, leave the facility (even if it is against the recommendations of healthcare providers), and be fully informed of their health conditions.
Correct Answer is C
Explanation
Choice A rationale:
Notify the charge nurse of the client's request for transfer. This action might be taken eventually, but it is not the first step. The nurse should directly address the client's concerns before escalating the situation to the charge nurse.
Choice B rationale:
Assure the client that their concern has been shared with the staff. Tell the client that future calls will be answered in a timely manner. While it's important to reassure the client, promising timely responses to calls before understanding their expectations might not effectively address the underlying issue. It's better to communicate openly with the client first.
Choice C rationale:
Ask the client to verbalize their expectations. This is the correct choice. By asking the client to express their expectations, the nurse can gather crucial information about the client's concerns and needs. This allows the nurse to address the specific issues that led to the client's dissatisfaction and work toward a resolution that aligns with the client's preferences.
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