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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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
The age of the client might impact the care plan, but it doesn't directly relate to the cost effectiveness of care. Older patients might have different health considerations, but the length of their stay and the services they require play a more significant role in cost evaluation.
Choice B rationale:
While the availability of community support groups can be beneficial for the client's overall well-being and recovery, it doesn't directly contribute to evaluating the cost effectiveness of care. Community support groups are more about psychosocial support than cost.
Choice C rationale:
This is the correct choice. The length of the client's stay directly affects the cost of care. Longer stays often involve more resources, medications, treatments, and staff time, leading to higher costs. Shorter and more efficient stays are generally more cost-effective.
Choice D rationale:
The type of insurance the client carries is relevant to the client's financial responsibility for their care, but it doesn't assist in evaluating the overall cost effectiveness of care. The insurance type might affect reimbursement rates, but it doesn't provide a comprehensive picture of cost efficiency.
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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