A nurse is performing an abdominal assessment on a client. Identify the sequence of actions the nurse should take.
Auscultation
Inspection
Palpation
Percussion
The Correct Answer is B, A, D, C
B. Inspection is the first step in an abdominal assessment because it allows the nurse to observe the shape, size, symmetry, contour, and movement of the abdomen. Inspection also helps to identify any abnormalities such as scars, lesions, masses, or distension.
A. Auscultation is the second step in an abdominal assessment because it allows the nurse to listen to the bowel sounds and vascular sounds of the abdomen. Auscultation should be performed before palpation or apercussion because these maneuvers could alter the sounds.
D. Percussion is the third step in an abdominal assessment because it allows the nurse to elicit sounds from different organs and structures in the abdomen. Percussion helps to determine the size, location, density, and consistency of the organs and to detect any fluid or air accumulation.
C. Palpation is the last step in an abdominal assessment because it allows the nurse to feel the texture, temperature, tenderness, and masses of the abdomen. Palpation should be performed gently and carefully to avoid causing pain or injury to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F"]
Explanation
A. This choice is correct because mental status changes, such as agitation, confusion, or delirium, are common signs of thyroid storm, which is a life-threatening complication of hyperthyroidism that occurs when there is excessive release of thyroid hormones.
B. This choice is incorrect because wound drainage is not a specific sign of thyroid storm, but rather a potential complication of any surgery that can indicate infection or bleeding.
C. This choice is correct because tachycardia, or increased heart rate, is a common sign of thyroid storm, which can result from increased metabolic demand and increased sensitivity to catecholamines.
D. This choice is incorrect because pain is not a specific sign of thyroid storm, but rather a common symptom of any surgery that can be managed with analgesics.
E. This choice is correct because hypertension, or increased blood pressure, is a common sign of thyroid storm, which can result from increased cardiac output and peripheral vascular resistance.
F. This choice is correct because hyperthermia, or increased temperature, is a common sign of thyroid storm, which can result from increased heat production and impaired heat dissipation.
Correct Answer is ["18"]
Explanation
The client weighs 198 lb, which is equivalent to (198 ÷ 2.2 = 90kg.
Therefore, the amount of mannitol for the test dose is 0.2 g/kg x 90 kg = 18 g.
The nurse should administer 18 g of mannitol IV bolus over 5 min as a test dose to the client who has severe oliguria.
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