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 C

Explanation

A. Monitor the client for manifestations of fluid overload: This action is not specifically related to C. difficile infection. Monitoring for fluid overload might be necessary in other situations, but it is not the appropriate action for this scenario.

B. Use alcohol hand sanitizer following client care: While alcohol-based hand sanitizers are effective against many pathogens, they are not effective against C. difficile spores. Washing hands with soap and water is necessary to remove the spores.

C. Disinfect equipment with bleach solution. This is the correct answer. Clostridium difficile (C. difficile) spores are resistant to many disinfectants, but they are killed by bleach. Therefore, equipment and surfaces should be cleaned with a bleach solution to prevent the spread of the infection.

D. Implement neutropenia isolation: Neutropenia isolation is a precautionary measure taken when a person has a low count of neutrophils, a type of white blood cell. This option is not directly related to C. difficile infection.

A. Blood glucose 150 mg/dL B. Potassium 2.5 mEq/L C. Weight loss of 3% of total body weight. D. Urine specific gravity 1.035

Correct Answer is B

Explanation

A. Blood glucose 150 mg/dL:
This blood glucose level is slightly elevated but not significantly concerning on its own. It may be related to stress or other factors. In the context of acute gastroenteritis, it might be secondary to dehydration, but it is not an immediate priority unless the client is diabetic.

B. Potassium 2.5 mEq/L:
This is the correct answer. Low potassium levels (hypokalemia) are a severe concern, especially in the context of acute gastroenteritis where there can be significant losses through vomiting and diarrhea. Hypokalemia can lead to cardiac arrhythmias and needs urgent correction.

C. Weight loss of 3% of total body weight:
While weight loss is an important parameter, a 3% weight loss is usually not an immediate concern. In cases of acute gastroenteritis, rapid weight loss might indicate severe dehydration, but this choice is not as urgent as addressing a severe electrolyte imbalance like hypokalemia.

D. Urine specific gravity 1.035:
This specific gravity indicates concentrated urine, which could be due to dehydration. While this finding is important and indicates the need for rehydration, it is not as urgent as correcting a critically low potassium level.

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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?

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