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 D
Explanation
The correct answer is choice D.
Choice A rationale:
“Auscultate the client’s bowel sounds.” While auscultating bowel sounds can provide information about the client’s gastrointestinal function, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.
Choice B rationale:
“Measure the client’s temperature.” Measuring the client’s temperature can help identify if the client has an infection, which could be causing the vomiting and diarrhea. However, it is not the priority assessment in this situation.
Choice C rationale:
“Check the client’s urine specific gravity.” Checking the client’s urine specific gravity can provide information about the client’s hydration status. However, it is not the priority assessment for a client who has been vomiting and experiencing diarrhea for the past 6 hours.
Choice D rationale:
“Obtain the client’s serum potassium level.” This is the correct answer. Prolonged vomiting and diarrhea can lead to significant loss of electrolytes, including potassium. A low potassium level (hypokalemia) can have serious effects, including cardiac arrhythmias. Therefore, obtaining the client’s serum potassium level is the priority assessment.
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.
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