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?
Percussion
Auscultation
Palpation
Inspection
The Correct Answer is C
Choice A reason: Percussion precedes palpation to assess abdominal resonance and organ size without altering bowel motility. Performing it last risks inaccurate findings, as palpation may stimulate peristalsis, changing resonance patterns. This sequence ensures reliable detection of abnormalities like organomegaly or fluid accumulation in the abdomen.
Choice B reason: Auscultation is done before palpation to capture natural bowel sounds. Manipulation during palpation can alter peristalsis, affecting auscultatory findings. Early auscultation ensures accurate detection of hypoactive or hyperactive bowel sounds, critical for diagnosing conditions like ileus or obstruction in abdominal assessments.
Choice C reason: Palpation is the final step, following inspection, auscultation, and percussion, to assess for tenderness or masses. This sequence prevents manipulation from altering earlier findings, ensuring accurate identification of abdominal abnormalities like peritonitis or organ enlargement, critical for a comprehensive physical examination.
Choice D reason: Inspection is the first step, providing a visual baseline of abdominal appearance, such as distension or scars. Performing it last misses initial cues guiding subsequent steps. Early inspection ensures no manipulation affects visual assessment, vital for identifying external signs of underlying abdominal pathology.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Amputation is not a contraindication for kidney donation, as it does not affect kidney function or surgical risks. Physical disability, if stable, does not preclude donation, so this condition is irrelevant to eligibility, making it incorrect.
Choice B reason: Primary glaucoma does not impact kidney function or donation safety. It is an eye condition unrelated to systemic health risks for donation, so it is not a contraindication, making this an incorrect choice for exclusion.
Choice C reason: Osteoarthritis, if mild, is not a contraindication for kidney donation, as it does not affect renal or surgical outcomes. Severe cases may pose mobility issues, but this is not typical, so it is incorrect as a contraindication.
Choice D reason: Hypertension is a contraindication for kidney donation, as it increases risks of renal damage and cardiovascular complications post-donation. It compromises long-term kidney function, aligning with transplant guidelines, making it the correct condition to identify.
Correct Answer is A
Explanation
Choice A reason: Applying nitroglycerin ointment in a thin, even layer ensures consistent absorption for angina relief, as specified by dosing guidelines (e.g., using a dosing paper). This maximizes efficacy and minimizes side effects like hypotension, aligning with manufacturer instructions, making it the correct teaching point.
Choice B reason: Applying to the forearm is not standard, as nitroglycerin ointment is typically applied to the chest, upper arm, or back for optimal absorption. Forearm application may reduce effectiveness due to skin thickness, making this an incorrect site choice.
Choice C reason: Applying every 4 hours is incorrect, as nitroglycerin ointment is typically applied 2-3 times daily, with a 12-hour nitrate-free interval to prevent tolerance. This frequency is too frequent and risks side effects, making it an inaccurate instruction.
Choice D reason: Massaging nitroglycerin ointment into the skin is contraindicated, as it alters absorption rates and may cause inconsistent dosing or irritation. The ointment is spread lightly and covered, making this instruction incorrect and potentially harmful for proper administration.
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