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:
Placing the wasted portion of the controlled substance in the sharp container is not correct. Wasted controlled substances should be disposed of according to specific regulations and facility protocols.
Choice B reason:
Asking a second nurse to record her signature when wasting an unused portion of the controlled substance is not a standard practice. The process for wasting controlled substances usually involves following specific documentation procedures, but this does not necessarily require a second nurse's signature.
Choice C reason:
Over-verifying the count total of the controlled substance after removing the amount needed is not a standard practice. It's important to maintain accurate records and documentation, but additional verification of the count total may not be necessary in this context.
Choice D reason:
Reporting any discrepancy in the count total of the controlled substance after administration is the appropriate action. When administering a controlled substance, it is important to accurately account for the medication before and after administration. Any discrepancy in the count of the controlled substance should be reported and documented according to facility policy. This helps ensure proper tracking and accountability of controlled substances, which is crucial for maintaining patient safety and preventing potential diversion or misuse.

A. Hyperextend the client's back while the fracture pan is in place. B. Keep the bed flat while the client is on the fracture pan. C. Encourage the client to try to defecate for 20 min while on the fracture pan. D. Place the shallow end of the fracture pan under the client's buttocks

Correct Answer is D

Explanation

A. Hyperextend the client's back while the fracture pan is in place: Hyperextending the client's back is not necessary and can cause discomfort or strain. The client's back should be kept in a neutral position.
B. Keep the bed flat while the client is on the fracture pan: Raising the head of the bed slightly can facilitate the client's positioning and defecation. It is not necessary to keep the bed completely flat.
C. Encourage the client to try to defecate for 20 minutes while on the fracture pan: Encouraging the client to try to defecate for a specific time frame is not necessary and may lead to discomfort or straining. The client should be allowed to take the time they need and not be rushed during this process.
D. Place the shallow end of the fracture pan under the client's buttocks: When using a fracture bedpan, the shallow end should be placed under the client's buttocks to allow for proper positioning. The higher, deeper end of the bedpan is positioned under the client's lower back.

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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 preparing to administer a controlled substance to a client for pain management. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage?

A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is postoperative and has a new prescription to advance her diet to full liquids. Which of the following foods should the nurse offer the client as a part of a full liquid diet?

A nurse is caring for a client who has a prescription for a 250 mL IV fluid bolus. The nurse administers a 500 mL IV bolus. Which of the following actions should the nurse take first?

A nurse is preparing to insert an IV catheter for an adult client. Which of the following actions should the nurse take?

A charge nurse in a long-term care facility is preparing an educational program about delirium for newly hired nurses. Which of the following statements should the nurse plan to include?