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 D

Explanation

A. Gloves are used to protect against direct contact with bodily fluids, not specifically for droplet transmission.

B. A gown is generally used for contact precautions or to protect from body fluid exposure, not droplet transmission.

C. Goggles are used to protect the eyes from splashes or droplets, but they are not typically required for droplet precautions unless there is a risk of eye exposure.

D. A mask is required for droplet precautions, as droplet transmission can occur when a person coughs or sneezes. Wearing a mask helps prevent the spread of respiratory droplets.

A. Place the client in a room with negative airflow. B. Wear a gown when providing care to the client. C. Ensure the client's room has HEPA filtration. D. Wear a mask when providing care to the client.

Correct Answer is D

Explanation

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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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

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