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 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.

A. Evaluating the healing of an incision B. Changing IV tubing C. Performing a simple dressing change D. Inserting an NG tube

Correct Answer is B

Explanation

Choice A reason:
Evaluating the healing of an incision is not necessary because it involves clinical judgment and assessment skills, which are generally beyond the scope of practice for assistive personnel.
Choice B reason:
Changing IV tubing is a task that can often be safely delegated to an assistive personnel (AP) who has been trained and deemed competent to perform this task. It is within the AP's scope of practice and doesn't require clinical judgment or assessment.
Choice C reason:
Performing a simple dressing change involves direct contact with a wound and requires knowledge of aseptic technique and wound care principles. This task is typically performed by licensed nursing personnel.
Choice D reason:
Inserting an NG tube is a complex procedure that requires specialized training and skill. It should be performed by a licensed nurse or another healthcare professional with the appropriate training and competence.

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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 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

A nurse is delegating client care tasks to assistive personnel. Which of the following tasks should the nurse delegate?

Correct Answer is B

Explanation

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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.)

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