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. Assist the adolescent in applying for Medicaid: Medicaid can provide essential prenatal care, delivery services, and pediatric coverage for low-income individuals. Helping the adolescent apply addresses both her financial and health concerns, supporting positive outcomes.

B. Refer the adolescent to local mental health clinic: While emotional support is important, this action doesn’t directly address her stated concern about affording and caring for the baby. It may be appropriate later but is not the immediate priority.

C. Contact the adolescent parent for assistance: Contacting family may be helpful if the adolescent consents, but it must respect her autonomy and confidentiality. It is not the nurse’s first step without permission or expressed need for family involvement.

D. Advise the adolescent to place the newborn for adoption: Suggesting adoption without the adolescent initiating that discussion may be inappropriate and coercive. Nurses should provide options neutrally and supportively, not direct decisions about parenting or adoption.

A. Prepare an IV bolus of dextrose 5% in water. B. Administer calcium gluconate IV. C. Position the client supine. D. Administer methylergonovine IM.

Correct Answer is B

Explanation

Rationale:

A. Prepare an IV bolus of dextrose 5% in water: Dextrose in water does not reverse magnesium toxicity. It may be used as a fluid carrier but does not serve as an antidote or address the neuromuscular and cardiac effects of excessive magnesium.

B. Administer calcium gluconate IV: Calcium gluconate is the antidote for magnesium sulfate toxicity. It helps reverse respiratory depression, muscle weakness, and cardiac conduction delays caused by high magnesium levels, making it the immediate intervention.

C. Position the client supine: The supine position can worsen hypotension by decreasing venous return, especially in pregnant clients. Left lateral positioning is generally preferred to improve circulation to vital organs and the fetus.

D. Administer methylergonovine IM: Methylergonovine is used to treat postpartum hemorrhage, but it is contraindicated in clients with hypertension or preeclampsia due to its vasoconstrictive effects. It does not treat magnesium toxicity and could increase blood pressure dangerously.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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