A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?

Auscultation

Inspection

Palpation

Percussion

Answer and Explanation

The Correct Answer is C

Rationale:

A. Auscultation: This step is performed after inspection and before percussion or palpation to avoid altering bowel sounds. It allows the nurse to assess for the presence, frequency, and character of bowel sounds without stimulating them artificially.

B. Inspection: This is the first step in the abdominal assessment. It involves visually examining the abdomen for contour, symmetry, skin changes, pulsations, or visible masses without touching the patient, helping establish a baseline.

C. Palpation: Palpation is the final step in abdominal assessment to prevent interference with bowel sounds. It allows the nurse to detect tenderness, masses, or organ enlargement, but should only be done after auscultation and percussion.

D. Percussion: This is done after auscultation and provides information on underlying structures, such as gas, fluid, or masses. It helps differentiate between dullness, resonance, or tympany across abdominal quadrants.

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Correct Answer is A

Explanation

Rationale:

A. 0.45% sodium chloride: This is a hypotonic solution that helps lower serum sodium levels by diluting extracellular sodium and promoting cellular rehydration. It is commonly used to treat hypernatremia when there is no significant fluid volume overload.

B. 0.9% sodium chloride: This isotonic solution contains the same concentration of sodium as the blood. It does not correct hypernatremia and may worsen it if sodium levels are already elevated, especially in dehydrated clients.

C. Lactated Ringer's: While this is an isotonic fluid, it contains sodium and electrolytes that do not help reduce high serum sodium levels. It is more appropriate for fluid resuscitation than for treating hypernatremia.

D. 3% sodium chloride: This hypertonic solution is used for severe hyponatremia, not hypernatremia. Administering it to someone with elevated sodium levels would further increase sodium concentration and worsen the condition.

A. Assess the client's lung sounds prior to the infusion. B. Infuse the blood over 4 hr. C. Verify with another nurse that the unit of blood is compatible with the client's blood type D. Prime the infusion tubing with 0.45% sodium chloride E. Don sterile gloves to prepare the blood administration setup.

Correct Answer is ["A","B","C"]

Explanation

Rationale:

A. Assess the client's lung sounds prior to the infusion: Pre-transfusion assessment of lung sounds is essential to detect any baseline abnormalities and to monitor for fluid overload or transfusion-related lung complications such as transfusion-associated circulatory overload.

B. Infuse the blood over 4 hr: Older adults are at increased risk for fluid overload, so transfusing packed RBCs slowly over 4 hours is appropriate and safer, as long as the blood is completely administered within the maximum 4-hour window from removal from refrigeration.

C. Verify with another nurse that the unit of blood is compatible with the client's blood type: A dual verification process is mandatory to ensure safe administration. The nurse must check the client’s ID, blood type, unit number, and expiration date with another licensed professional before initiating the transfusion.

D. Prime the infusion tubing with 0.45% sodium chloride: Only 0.9% sodium chloride (normal saline) should be used to prime and flush blood transfusion tubing. Hypotonic solutions like 0.45% sodium chloride can cause hemolysis and should never be used with blood products.

E. Don sterile gloves to prepare the blood administration setup: Sterile gloves are not necessary for setting up a blood transfusion. Clean gloves are sufficient for handling equipment and initiating IV therapy, following standard precautions.

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A nurse is performing an abdominal assessment as part of a client's comprehensive physical examination. Which of the following is the final step the nurse should perform?

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Explanation

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