A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment.
(Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
Inspect the abdomen for skin integrity.
Ask the client about having a history of abdominal pain.
Auscultate the abdomen for bowel sounds.
Percuss the abdomen in each of the four quadrants.
Palpate the abdomen gently for tenderness.
The Correct Answer is A,B,C,D,E
1. a) Inspect the abdomen for skin integrity: The first step in an abdominal assessment is inspection. The nurse should visually examine the abdomen for any abnormalities such as skin changes, scars, distention, or masses.
2. b) Ask the client about having a history of abdominal pain: Gathering a history of abdominal pain is crucial as it provides context for the physical findings. This step helps identify any underlying conditions that may influence the assessment.
3. c) Auscultate the abdomen for bowel sounds: Auscultation should be performed before palpation and percussion to avoid altering the bowel sounds. The nurse listens for the presence, frequency, and character of bowel sounds in all four quadrants.
4. d) Percuss the abdomen in each of the four quadrants: Percussion helps to assess the presence of fluid, air, or masses in the abdomen. The nurse taps on the abdomen to listen for sounds that indicate the underlying structures.
5. e) Palpate the abdomen gently for tenderness: Palpation is the final step and involves gently pressing on the abdomen to check for tenderness, masses, or organ enlargement. This step should be done last to avoid causing discomfort or altering the findings of the other steps.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: I’ll Be Sure to Eat More Foods with Vitamin K
This statement indicates a misunderstanding. While vitamin K is essential for blood clotting, consuming large amounts of vitamin K can interfere with the effectiveness of warfarin. Patients on warfarin should maintain a consistent intake of vitamin K to avoid fluctuations in their INR levels.
Choice B reason: I’ll Take Aspirin for My Headaches
This statement also indicates a misunderstanding. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the risk of bleeding when taken with warfarin. Patients should consult their healthcare provider before taking any new medications, including over-the-counter drugs.
Choice C reason: I’ll Use My Electric Razor for Shaving
This statement indicates an understanding of the teaching. Using an electric razor instead of a traditional blade can help prevent cuts and bleeding, which is particularly important for patients on anticoagulant therapy like warfarin.
Choice D reason: It’s Okay to Have a Couple of Glasses of Wine with Dinner Each Evening
This statement indicates a misunderstanding. Alcohol can affect the metabolism of warfarin and increase the risk of bleeding. Patients on warfarin should limit their alcohol intake and discuss their drinking habits with their healthcare provider to ensure safe use of the medication.
Correct Answer is A
Explanation
Choice A reason:
An infant who has pertussis and is receiving oxygen via nasal cannula: Pertussis, also known as whooping cough, is a highly contagious respiratory disease that can be particularly severe in infants. The fact that the infant is receiving oxygen indicates respiratory distress, which is a critical condition requiring immediate attention. Infants with pertussis are at high risk for complications such as pneumonia, apnea, and respiratory failure. Therefore, this patient should be assessed first to ensure their airway and breathing are adequately supported.
Choice B reason:
A school-age child who has diabetes mellitus and requires blood glucose monitoring: While it is important to monitor blood glucose levels in children with diabetes mellitus to prevent hypo- or hyperglycemia, this condition is generally more stable and manageable compared to the acute respiratory distress seen in the infant with pertussis. Blood glucose monitoring can be scheduled and managed, making it a lower priority in this context.
Choice C reason:
An adolescent who was admitted to the unit in sickle cell crisis and is ready for discharge instructions: Sickle cell crisis can be extremely painful and requires careful management. However, if the adolescent is ready for discharge, it indicates that their condition has stabilized. Providing discharge instructions is important but can be deferred until more critical patients are assessed.
Choice D reason:
A toddler who has both arms in casts and needs to be fed his breakfast: While this toddler requires assistance with feeding due to their casts, this situation does not pose an immediate threat to their health. Feeding can be managed after ensuring that more critical patients, such as the infant with pertussis, are stable.
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