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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Increased platelet count: Preeclampsia is often associated with thrombocytopenia (low platelet count), not an increase. A falling platelet count can be a warning sign of worsening disease or progression to HELLP syndrome.
B. Increased protein in urine: Proteinuria is one of the hallmark signs of preeclampsia, resulting from glomerular damage in the kidneys. A 24-hour urine protein test or dipstick is commonly used to detect elevated protein levels during pregnancy.
C. Decreased BUN: Blood urea nitrogen (BUN) may increase if renal perfusion is compromised, but a decrease is not typical in preeclampsia. Kidney involvement often leads to elevated BUN and creatinine levels.
D. Decreased serum uric acid: Preeclampsia usually causes elevated serum uric acid levels due to decreased renal clearance. A drop in uric acid would be inconsistent with this diagnosis
Correct Answer is D
Explanation
Rationale:
A. Raise the head of the bed when transferring a client from a bed to a stretcher: Raising the head of the bed alters body mechanics and may complicate the transfer by increasing the angle of elevation, which can lead to strain or improper alignment during the move.
B. Use a pillow underneath the client's head when repositioning a client in bed: A pillow can aid in comfort but does not contribute to safe body mechanics during repositioning. It may also interfere with alignment or reduce the ability to properly lift or turn the client.
C. Transfer on the client's weaker side when moving a client from a bed to a chair: Transferring toward the weaker side increases the risk of instability and falls. Safe ergonomic practice involves moving clients toward their stronger side to encourage participation and minimize staff effort.
D. Use a lateral transfer device when moving a client from a bed to a stretcher: Lateral transfer devices reduce friction between surfaces, making it easier to move the client without excessive force. This protects both the client and the nurse from musculoskeletal injuries and supports safe practice.
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