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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer is c. Receiving moderate sedation.
a. Removal of staples from a surgical wound: This procedure is typically considered routine and minimally invasive, involving the removal of staples used for wound closure. While it involves physical manipulation of the wound site, it does not carry significant risks or require the alteration of the patient's consciousness. Therefore, obtaining informed consent for this procedure is not typically necessary as it falls within the standard of care for post-operative wound management.
b. Providing a sputum specimen: Collecting a sputum specimen is a non-invasive procedure commonly performed to aid in the diagnosis of respiratory conditions such as infections or chronic lung diseases. It involves expectorating mucus from the respiratory tract, which does not pose significant risks to the patient. As such, informed consent is usually not required for this procedure since it is relatively simple and does not involve any invasive interventions or alteration of consciousness.
c. Receiving moderate sedation: Correct. Moderate sedation involves the administration of drugs, typically benzodiazepines or opioids, to induce a state of decreased consciousness and relaxation while maintaining the patient's ability to respond to verbal commands and physical stimulation. This procedure carries inherent risks, including respiratory depression, cardiovascular complications, and potential allergic reactions to the medications used. Due to the potential for adverse effects and the altered state of consciousness induced by moderate sedation, informed consent is necessary to ensure that patients understand the risks and benefits of the procedure before it is performed.
d. Collection of a blood specimen for ABGs: Arterial blood gas (ABG) analysis involves the collection of a blood sample from an artery, typically the radial artery in the wrist, to assess the patient's acid-base balance, oxygenation status, and ventilation. While this procedure does involve puncturing the skin and accessing the arterial blood supply, it is considered a standard diagnostic test in many clinical settings. However, the invasiveness of the procedure and potential risks such as bleeding, hematoma formation, and arterial injury may necessitate informed consent in certain situations, especially if the patient has underlying coagulopathies or other risk factors that could increase the likelihood of complications.
Correct Answer is B
Explanation
The answer isb. "Check the urinary output at 11:00 for John Doe and report it to me immediately.”
a. "Take vital signs every 2 hours for the client who had a cholecystectomy in room 6122.” is wrong because it does not specify which client to monitor.The AP should know the client’s name and room number for identification and safety purposes.
c. "Report to me if the chest tube drainage is excessive for Jane Doe in room 2438.” is wrong because it does not define what constitutes excessive drainage.The nurse should provide clear and measurable criteria for the AP to follow.
d. "Please notify me of any clients whose vital signs or blood glucose levels are significant.” is wrong because it is vague and does not indicate which clients to check, how often to check them, or what values are significant.The nurse should provide specific and individualized instructions for each client
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