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. Upper left quadrant: Pain in the upper left quadrant of the abdomen can be associated with issues related to the spleen, stomach, or parts of the colon. It's not a typical location for pain related to diverticular disease.

B. Upper right quadrant: Pain in the upper right quadrant is often associated with issues related to the liver, gallbladder, or part of the colon. Again, not a typical location for diverticular disease-related pain.

C. Lower left quadrant: This is the correct answer. Diverticular disease often causes pain in the lower left quadrant of the abdomen, particularly if the inflammation or infection is in the sigmoid colon, which is a common site for diverticula.

D. Lower right quadrant: Pain in the lower right quadrant can be related to issues with the appendix or parts of the colon. It's not a typical location for diverticular disease-related pain.

A. Place the client in a supine position. B. Withdraw the tube if the client gags during insertion. C. Measure the tube for insertion from the tip of the nose to the umbilicus. D. Instruct the client to place his chin to his chest and swallow.

Correct Answer is D

Explanation

A. Place the client in a supine position.
Placing the client in a high Fowler's position (sitting upright) is the appropriate position for inserting a nasogastric tube. This position helps facilitate the passage of the tube through the nasopharynx and into the esophagus and stomach.

B. Withdraw the tube if the client gags during insertion.
Gagging during insertion is a normal response. Advancing the tube slowly and having the client swallow can help pass the tube through the nasopharynx.

C. Measure the tube for insertion from the tip of the nose to the umbilicus.
The correct measurement for insertion is from the tip of the nose to the earlobe and then down to the xiphoid process (not the umbilicus).

D. Instruct the client to place his chin to his chest and swallow.
This instruction is appropriate. Asking the client to flex their head slightly forward and swallow helps guide the tube into the esophagus.

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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

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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