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
Choice A rationale:
Setting target dates for completion is an important step, but it should come after goals and objectives have been established. Goals and objectives provide the foundation for developing a timeline and action plan.
Choice B rationale:
Identifying areas of support is valuable, but it's not the next immediate action after developing the initial plan. Before seeking support, the nurse should clarify the goals and objectives to ensure that the support is aligned with the intended outcomes.
Choice C rationale:
Determining goals and objectives is the next logical step after developing the initial plan. Goals and objectives help guide the committee's work and ensure that the policy revisions are purposeful and aligned with the desired outcomes.
Choice D rationale:
Implementing recommended strategies is a subsequent action that follows the establishment of goals and objectives. Without clear goals and objectives, the strategies might lack direction and cohesiveness.
Correct Answer is D
Explanation
Choice A rationale:
Reporting the findings to the hospital ethics committee is not the appropriate action in this scenario. Ventilator-associated pneumonia (VAP) is a clinical issue related to patient care and safety, not an ethical concern. The hospital ethics committee is generally responsible for addressing ethical dilemmas and conflicts.
Choice B rationale:
Alerting central supply is not the correct action in this situation. Central supply typically handles the procurement and distribution of medical supplies, equipment, and materials. While maintaining proper equipment and supplies is important, addressing VAP requires a focus on infection prevention and patient care practices.
Choice C rationale:
Filling out an incident report is not the best course of action for addressing an increase in ventilator-associated pneumonia. Incident reports are typically used to document unexpected events, accidents, or errors that occur in the healthcare setting. However, addressing the rise in VAP involves implementing measures to prevent and control infections, which falls under the purview of the quality improvement team.
Choice D rationale:
The correct action is to notify the quality improvement team. Ventilator-associated pneumonia is a healthcare-associated infection that can lead to serious complications for patients on ventilators. The quality improvement team is responsible for monitoring and improving the quality of patient care, including infection prevention and control. By notifying the quality improvement team, the nurse manager can initiate a comprehensive review of current practices, identify potential areas for improvement, and implement evidence-based interventions to reduce the incidence of VAP.
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.