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

Choice A reason:
Attaching the drainage bag to the side rails of the bed can create tension on the catheter and increase the risk of trauma or dislodgment.
Choice B reason:
Emptying the drainage bag when it is three-quarters full is appropriate to prevent the bag from becoming too heavy and pulling on the catheter. However, this is a practice for maintaining bag weight, not part of the overall care plan.
Choice C reason:
Taping the catheter to the lower abdomen is not recommended. Taping the catheter can cause irritation, tension, and skin breakdown, increasing the risk of infection and trauma to the urethra. The catheter should be secured to the thigh using a catheter securement device if necessary.
Choice D reason:
Keeping the drainage bag below the level of the bladder is the correct recommendation. When caring for a client with an indwelling urinary catheter, it is important to maintain proper catheter and drainage bag positioning to prevent complications. Keeping the drainage bag below the level of the bladder helps promote the free flow of urine, prevent reflux of urine into the bladder, and minimize the risk of urinary tract infections.

A. Shakiness B. Cool skin C. Thirst D. Confusion

Correct Answer is C

Explanation

A. Shakiness (tremors) is more commonly associated with hypoglycemia, where blood glucose levels drop too low. It is not typically a symptom of hyperglycemia. B. Cool skin is not a typical symptom of hyperglycemia. It is more commonly associated with poor peripheral circulation, which can occur in diabetes but is not specific to hyperglycemia itself. C. Thirst (polydipsia) is a common symptom of hyperglycemia in clients with diabetes mellitus. When blood glucose levels are elevated, the kidneys work to eliminate the excess glucose through urine, leading to increased urine production (polyuria). This increased urine production can result in dehydration, triggering the sensation of thirst as the body tries to maintain fluid balance. Thirst is a more common early indicator. D. Confusion can occur in severe cases of both hyperglycemia (diabetic ketoacidosis) and hypoglycemia. However, it is not specific enough on its own to indicate hyperglycemia without other symptoms like thirst and polyuria.

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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 female client who has an indwelling urinary catheter. Which of the following actions should the nurse include in the plan?

Correct Answer is D

Explanation

A nurse is assessing a client who has diabetes mellitus prior to performing a blood glucose test. Which of the following findings should indicate to the nurse that the client has hyperglycemia?

Correct Answer is C

Explanation

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