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. Documenting that the nurse was unable to measure the temperature is unnecessary if the nurse can follow the correct procedure of waiting and measuring after a proper interval.

B. The nurse should wait at least 30 minutes after the client has eaten or consumed ice chips before measuring the oral temperature to ensure an accurate reading.

C. Proceeding immediately to measure the temperature after consuming ice chips may result in an inaccurate reading, as it can lower the temperature of the mouth.

D. Providing warm water and waiting 5 minutes may not be sufficient to correct the cooling effect of the ice chips on the oral cavity.

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

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