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. Wet-to-dry gauze dressings are typically used for more severe wounds, particularly for debridement, and are not appropriate for a stage I pressure ulcer.

B. A transparent dressing is appropriate for a stage I pressure ulcer because it provides a barrier to moisture while allowing for continuous observation of the area without disturbing the skin.

C. Hydrogel dressings are typically used for more complex wounds to hydrate and provide a moist healing environment but are not necessary for a stage I ulcer.

D. Alginate dressings are used for heavily exudating wounds and would not be appropriate for a stage I pressure ulcer.

A. Contact B. Droplet C. Protective D. Airborne

Correct Answer is B

Explanation

A. Contact precautions are used for infections that are spread through direct contact with contaminated surfaces or items.

B. Droplet precautions are used for infections spread through respiratory droplets, such as influenza.

C. Protective isolation is used for clients with weakened immune systems, but TB requires airborne precautions, not protective isolation.

D. Tuberculosis (TB) is transmitted via airborne particles, so the nurse should initiate airborne precautions, including the use of an N95 respirator, negative pressure rooms, and other measures to prevent the spread of TB.

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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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