A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Percuss, inspect, auscultate, palpate

Auscultate, inspect, palpate, percuss

Palpate, percuss, inspect, auscultate

Inspect, auscultate, percuss, palpate

Answer and Explanation

The Correct Answer is D

A. Percuss, inspect, auscultate, palpate: This sequence is incorrect because inspection should be performed first to assess the abdomen visually.

B. Auscultate, inspect, palpate, percuss: This sequence is incorrect because auscultation should follow inspection and before palpation and percussion.

C. Palpate, percuss, inspect, auscultate: This sequence is incorrect as palpation and percussion should not come before inspection.

D. Inspect, auscultate, percuss, palpate: This is the correct sequence. Inspection is first, followed by auscultation to listen to bowel sounds, then percussion to assess for fluid or gas, and finally palpation to check for tenderness or masses.

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Correct Answer is B

Explanation

A. Systolic murmur: Systolic murmurs occur during systole and include conditions like aortic stenosis or mitral regurgitation.

B. Diastolic murmur: Aortic insufficiency/regurgitation occurs during diastole when the aortic valve fails to close properly, allowing blood to flow back into the left ventricle.

C. Absent murmur: Aortic insufficiency/regurgitation is not classified as absent; it is detectable with auscultation.

D. Very faint murmur: Although aortic regurgitation murmurs can vary in intensity, the classification pertains to the timing of the murmur, not its loudness.

A. Auscultate the anatomic area with a stethoscope. B. Use Doppler ultrasonography to locate the pulse. C. Ask another nurse to assess the pulse. D. Document absence of dorsalis pedis pulse.

Correct Answer is B

Explanation

A. Auscultating the area may not provide accurate information about the pulse if it is not palpable, though it can be part of the assessment if Doppler is unavailable.

B. Using Doppler ultrasonography is the most appropriate next step to accurately assess the pulse if it is not palpable, especially in older adults where pulses may be difficult to detect.

C. Asking another nurse to assess the pulse may not address the underlying issue of why the pulse is not palpable and does not provide additional information.

D. Documenting the absence of the dorsalis pedis pulse without further investigation could be premature, as Doppler ultrasonography should be used to confirm its absence.

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A group of students is preparing for their clinical experience, during which they are required to demonstrate the techniques for assessing the abdomen. The students demonstrate understanding of the proper sequence when they demonstrate the techniques in which order?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Aortic insufficiency/regurgitation murmur is classified as a:

Correct Answer is B

Explanation

The nurse is unable to palpate the dorsalis pedis pulse on an older adult client. What would be most appropriate for the nurse to do next?

Correct Answer is B

Explanation

The nurse refers an older adult client for further evaluation after the nurse assesses warm skin and brown pigmentation around the ankles. The nurse suspects which of the following?

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