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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["10"]
Explanation
To calculate the number of milliliters (mL) of the hydroxyzine oral suspension to administer, you can use the following formula:
Dose (mL) = Ordered Dose (mg)/ Stock Concentration (mg/mL)
In this case:
- Ordered Dose = 50 mg
- Stock Concentration = 25 mg/5 mL
First, calculate the mg per mL from the stock concentration:
mg per mL = 25 mg/ 5 mL= 5 mg/mL
Now, use the formula to find the mL to administer:
Dose (mL) = 50 mg/ 5 mg/mL = 10 mL
So, the nurse should administer 10 mL of hydroxyzine oral suspension.
Correct Answer is B
Explanation
A. Troponin:
Troponin is a protein found in the heart muscle. Elevated levels of troponin in the blood indicate damage to the heart, often due to a heart attack or other cardiac issues. This marker is crucial in diagnosing heart-related problems.
B. Albumin:
Albumin is a protein produced by the liver and is essential for maintaining blood volume and regulating fluid balance. It also helps transport various substances in the blood. Low levels of albumin are indicative of malnutrition, liver disease, or kidney disorders.
C. D-dimer:
D-dimer is a substance in the blood that is released when a blood clot breaks up. Elevated levels of D-dimer can indicate the presence of an abnormal blood clot, but it is not specific to malnutrition. It is often used in diagnosing conditions like deep vein thrombosis (DVT) or pulmonary embolism (PE).
D. Creatinine:
Creatinine is a waste product produced by the muscles and excreted by the kidneys. Creatinine levels in the blood can indicate how well the kidneys are functioning. Elevated levels can suggest kidney damage or other kidney-related issues but are not directly related to malnutrition.
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