A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

Percuss

Auscultate.

Palpate.

Inspect

Answer and Explanation

The Correct Answer is D

A. Percuss:
Percussion involves tapping the abdomen with the fingers to assess for areas of dullness or resonance. Dullness might indicate organ enlargement or mass, while resonance is the typical sound over air-filled structures. This step helps identify the borders and size of organs.

B. Auscultate:
Auscultation involves listening to the abdomen using a stethoscope. The nurse listens for bowel sounds, which are the noises made by the movement of the intestines. Absence or abnormal bowel sounds can indicate intestinal obstruction or other gastrointestinal issues.

C. Palpate:
Palpation involves gently pressing the abdomen to assess for tenderness, masses, or areas of discomfort. This step helps identify areas of pain or tenderness, guarding, or rigidity, which might indicate inflammation, infection, or other abdominal issues.

D. Inspect:
Inspection involves visually assessing the abdomen for any visible abnormalities such as scars, distention, pulsations, or visible masses. It's the first step in the abdominal assessment process as it provides initial information about the overall condition of the abdomen before physical contact.

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Correct Answer is B

Explanation

A. To remove gastric acid that might cause dyspepsia:
This statement is not accurate. Measuring gastric residuals is not done to remove gastric acid but rather to ensure that the previous feeding has been digested and moved into the intestines before the next feeding is administered.

B. To identify delayed gastric emptying:This is the correct purpose. Measuring gastric residual helps assess whether the stomach is properly emptying its contents. High residual volumes can indicate delayed gastric emptying, which can increase the risk of aspiration and other complications during enteral feeding.

C. To determine the client's electrolyte balance:
Measuring gastric residuals is not used to assess the client's overall electrolyte balance. Electrolyte balance is typically assessed through blood tests and clinical evaluations, not by checking gastric residuals.

D. To confirm the placement of the NG tube:
Although verifying NG tube placement is critical before feeding, this is typically done by checking the tube’s external length, aspirating gastric contents, and confirming placement through pH testing or an X-ray, not by measuring gastric residual.

A. Docusate B. A bowel cathartic medication. C. Aspirin D. A corticosteroid medication

Correct Answer is D

Explanation

A. Docusate:
Docusate is a stool softener used to prevent constipation and straining during bowel movements. It is not typically used as a treatment for acute exacerbation of ulcerative colitis.

B. A bowel cathartic medication:
Bowel cathartic medications are laxatives that promote bowel movements. They are generally not used to treat acute exacerbation of ulcerative colitis and can sometimes worsen symptoms in individuals with inflammatory bowel disease.

C. Aspirin:
Aspirin is a nonsteroidal anti-inflammatory drug (NSAID) that can worsen symptoms of inflammatory bowel disease and is generally avoided in individuals with ulcerative colitis.

D. A corticosteroid medication:
This is the correct answer. Corticosteroids, such as prednisone, are often used to reduce inflammation in the colon during acute exacerbations of ulcerative colitis. They help in managing the symptoms and promoting healing of the inflamed intestinal lining.

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A nurse is planning to collect data about the abdomen of a client who reports "stomach pain". Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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