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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is B
Explanation
Choice A reason:
Needing a new hearing aid every year is not accurate. Hearing aids are not typically replaced annually unless there is a specific issue or significant changes in hearing.
Choice B reason:
"I should gradually increase the time that I wear the hearing aid. “This statement indicates an understanding of the appropriate approach to adapting to a new hearing aid. Gradually increasing the time spent wearing the hearing aid allows the individual to acclimate to the new sounds and avoid overwhelming the auditory system. Starting with shorter periods of use and gradually extending the time can help improve comfort and effectiveness.
Choice C reason:
Leaving the battery in the hearing aid when not in use can lead to battery drain and potential damage. It's important to remove the battery when the hearing aid is not being used.
Choice D reason:
Turning the hearing aid up to the highest volume immediately after insertion is not appropriate. Starting at a lower volume and gradually adjusting as needed is a more appropriate approach to prevent discomfort or potential damage to the ears.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.