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.

Answer and Explanation

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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Correct Answer is A

Explanation

Choice A reason:

Place a black tag on the client’s upper body and attempt to help the next client in need: In mass casualty incidents, triage is used to prioritize treatment based on the severity of injuries and the likelihood of survival. A black tag indicates that the victim is deceased or has injuries that are not compatible with life and that resources should be directed to those who have a better chance of survival. Since the client remains apneic even after repositioning the airway, it indicates that they are not breathing and have a very low chance of survival.

Choice B reason:

Reposition the client’s upper airway a second time before assessing his respirations: While ensuring the airway is open is crucial, if the client remains apneic after the initial repositioning, further attempts are unlikely to be successful in a mass casualty scenario where time and resources are limited2. The priority is to move on to other victims who may have a higher chance of survival.

Choice C reason:

Start CPR: In a mass casualty situation, CPR is typically not initiated for victims who are apneic and pulseless due to the need to allocate resources to those who have a higher likelihood of survival3. The focus is on providing immediate care to those who can benefit the most from it.

Choice D reason:

Place a red tag on the client’s upper body and obtain immediate help from other personnel: A red tag is used for victims who require immediate life-saving interventions and have a high chance of survival if treated promptly4. Since the client is apneic and remains so after airway repositioning, they do not meet the criteria for a red tag.

Correct Answer is ["5"]

Explanation

Step 1: Determine the total volume to be infused. = 1 liter (L)

Step 2: Convert the total volume from liters to milliliters (mL). Calculation: 1 L × 1000 mL/L = 1000 mL

Step 3: Determine the infusion rate. = 200 mL/hr

Step 4: Calculate the infusion time in hours. Calculation: 1000 mL ÷ 200 mL/hr = 5 hours

Step 5: Round the answer to the nearest whole number if necessary. = 5 hours (no rounding needed)

The nurse should expect the IV pump to infuse over 5 hours.

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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.)

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A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

Correct Answer is ["5"]

Explanation

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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.)