A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Percuss all four quadrants of the abdomen to measure sound quality.

Provide adequate lighting to inspect the abdomen.

Listen to the abdominal arteries using the bell of a stethoscope.

Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen.

Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen.

Answer and Explanation

The Correct Answer is B, C, E, D, A

B. Provide adequate lighting to inspect the abdomen: Adequate lighting is important to ensure that the nurse can clearly see and assess the client's abdominal area. This step helps identify any visible abnormalities, such as skin changes, scars, masses, or distention.

C. Listen to the abdominal arteries using the bell of a stethoscope: Listening to the abdominal arteries helps the nurse assess blood flow and detect any abnormal vascular sounds, such as bruits or murmurs. This step provides information about vascular health and potential issues related to blood flow.

E. Locate liver and spleen borders by pressing hands 2.5 to 7.5 cm (1 to 3 in) into the abdomen: Palpating and locating the liver and spleen borders help assess the size and position of these organs. It can help identify hepatomegaly (enlarged liver) or splenomegaly (enlarged spleen), which could indicate various underlying conditions.

D.Check for areas of tenderness by pressing fingers 1.3 cm (0.5 in) into the abdomen: Palpating the abdomen for tenderness helps identify areas of discomfort or pain. It can provide information about potential inflammation, organ enlargement, or other sources of discomfort

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Correct Answer is D

Explanation

A. Develop a plan for the client to integrate the change into her lifestyle: Developing a plan for integrating change into one's lifestyle is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the focus is on considering change rather than developing a detailed plan.
B. Assist the client in setting goals to make the change: Setting specific goals is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the client is not yet ready to commit to specific goals.
C. Recommend small changes for the client to make to change her behavior over time: During the contemplation stage of health behavior change, clients are considering making a change but are not yet committed to taking immediate action. This is also more suitable for the preparation or action stages.
D. In the contemplation stage, the client is aware of the problem and is considering making a change but has not yet committed to action. Providing information about the benefits can help the client move toward the next stage of change.

A. A blood glucose level of 110 mg/dl. B. Diarrhea one time in a 24-hr period C. A weight gain of 0.91 kg (2 lb) in 2 days D. A gastric residual of 300 mL at the end of the shift

Correct Answer is C

Explanation

Choice A reason:
A blood glucose level of 110 mg/dl: A slightly elevated blood glucose level could be expected in response to enteral feeding.
Choice B reason:
Diarrhea one time in a 24-hour period is incorrect. Diarrhea can occur as a side effect of enteral feeding due to changes in the digestive process.
Choice C reason:
An unexpected finding when a client is receiving continuous enteral feeding via an NG tube is a rapid and significant weight gain of 0.91 kg (2 lb) in just 2 days. This could indicate fluid overload, which might be caused by excessive fluid intake or inadequate fluid removal by the body. Rapid weight gain should be assessed and reported as it could be a sign of underlying issues that need to be addressed.
Choice D reason:
A gastric residual of 300 mL at the end of the shift is incorrect. Gastric residuals can fluctuate during continuous enteral feeding, and a residual of 300 mL may not necessarily be unexpected depending on the client's overall condition and the healthcare provider's guidelines.

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A nurse is preparing to perform a physical assessment of a client's abdomen. Identify the sequence in which the nurse should perform the following steps. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who is concerned about her tobacco smoking habits and is in the contemplation stage of health behavior change. Which of the following actions should the nurse plan to take during this stage?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving continuous enteral feeding via NG tube. Which of the following is an unexpected finding?

Correct Answer is C

Explanation

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