A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Inspect

Palpate

Auscultate

Percuss

Answer and Explanation

The Correct Answer is A

A. Inspection is usually done first to observe any obvious abnormalities, but it is not the immediate action when the client reports pain.

B. Palpation should be done last, as it can cause discomfort or alter the findings of other assessment techniques.

C. Auscultating the abdomen should be done second after inspection. This is recommended because bowel sounds should be assessed before palpation, as palpation may alter the sounds.

D. Percussion can follow auscultation, but it is not the immediate action.

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Correct Answer is B

Explanation

A. Contact precautions are not necessary for hepatitis C unless there is visible contamination of the environment with blood.

B. Hepatitis C is spread primarily through blood-to-blood contact, so the nurse should implement standard precautions, which include wearing gloves and other protective barriers as necessary.

C. Droplet precautions are used for infections spread by respiratory droplets, not for hepatitis C.

D. Airborne precautions are used for diseases that spread through airborne particles, such as tuberculosis.

A. Bilateral bowel sounds in lower quadrants B. Symmetrical convex sphere shape C. Ecchymosis D. Concave umbilicus

Correct Answer is C

Explanation

A. Bilateral bowel sounds in the lower quadrants are normal and do not require further investigation unless they are abnormal in frequency or tone.

B. A symmetrical convex sphere shape of the abdomen can be a normal finding, especially in a well-nourished individual.

C. Ecchymosis (bruising) may be a sign of trauma, bleeding disorders, or other underlying health conditions that require further investigation.

D. A concave umbilicus may be normal or could indicate a past surgical history or conditions like malnutrition, but it doesn't inherently require investigation unless associated with other symptoms.

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A nurse is assessing a client's abdomen who reports stomach pain. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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