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. Discarding the dressing in the bedside trash receptacle without proper containment is unsafe and not compliant with infection control standards.

B. Double-bagging the dressing is unnecessary unless required by facility protocols, but it should still be disposed of in a biohazard waste container.

C. Disposing of the dressing in a standard trash receptacle without proper precautions is not appropriate.

D. A wound dressing saturated with blood and purulent drainage is considered biohazardous and should be disposed of in a biohazard waste container to prevent the spread of infection.

A. Wet-to-dry gauze dressing B. Transparent dressing C. Hydrogel dressing D. Alginate dressing

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.

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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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