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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Decrease the Infusion Rate on the IV
Decreasing the infusion rate on the IV is the appropriate action to take when a client experiences flushing of the neck and tachycardia while receiving vancomycin. These symptoms are indicative of vancomycin flushing syndrome (VFS), also known as “red man syndrome,” which is a reaction caused by the rapid infusion of vancomycin. Slowing the infusion rate allows the body more time to metabolize the drug and can help alleviate the symptoms.
Choice B reason: Document that the Client Experienced an Anaphylactic Reaction to the Medication
Documenting that the client experienced an anaphylactic reaction is not accurate in this scenario. Vancomycin flushing syndrome is an anaphylactoid reaction, not an anaphylactic one. Anaphylactoid reactions are not mediated by IgE antibodies and do not require prior sensitization to the drug. Therefore, it is important to distinguish between the two and document the reaction correctly.
Choice C reason: Change the IV Infusion Site
Changing the IV infusion site is not necessary in this case. The symptoms of flushing and tachycardia are related to the rate of vancomycin infusion, not the site of infusion. Therefore, changing the site would not address the underlying issue.
Choice D reason: Apply Cold Compresses to the Neck Area
Applying cold compresses to the neck area may provide some symptomatic relief, but it does not address the root cause of the reaction. The primary intervention should be to slow the infusion rate to prevent further release of histamine and alleviate the symptoms.
Correct Answer is A
Explanation
Choice A reason:
Check the drainage for glucose: Clear drainage from the nasal packing after a transsphenoidal hypophysectomy could indicate a cerebrospinal fluid (CSF) leak. CSF leaks are a serious complication that can occur after this type of surgery. Testing the drainage for glucose is a quick and effective way to determine if the fluid is CSF, as CSF contains glucose, whereas normal nasal secretions do not. Identifying a CSF leak promptly is crucial to prevent further complications such as meningitis.
Choice B reason:
Notify the client’s provider: While notifying the provider is important, it should be done after confirming the nature of the drainage. If the drainage is indeed CSF, the provider needs to be informed immediately. However, the initial step should be to check the drainage for glucose to confirm the suspicion.
Choice C reason:
Document the amount of drainage: Documentation is always important in nursing care, but it is not the immediate priority in this situation. The primary concern is to identify the nature of the drainage to address any potential complications promptly.
Choice D reason:
Obtain a culture of the drainage: Obtaining a culture can help identify any infections, but it is not the first step in this scenario. The immediate concern is to determine if the drainage is CSF, which requires checking for glucose.
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