A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Deep palpation

Light palpation

Auscultation

Inspection

Answer and Explanation

The Correct Answer is D,C,B,A

Rationale:

D. Inspection: This is always the first step in any physical assessment. The nurse observes the abdomen for contour, symmetry, skin condition, and any visible movements or abnormalities.

C. Auscultation: Performed before palpation to avoid altering bowel sounds. Listening to bowel and vascular sounds provides key information about gastrointestinal activity and blood flow.

B. Light palpation: Conducted next to assess for tenderness, guarding, and superficial masses. This helps ensure client comfort and provides a baseline before deeper pressure is applied.

A. Deep palpation: Done last to evaluate organ size, deep masses, or tenderness. It can stimulate peristalsis or discomfort, so it follows the less invasive steps to minimize changes to assessment findings.

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Correct Answer is C

Explanation

Rationale:

A. Oxytocin: Oxytocin is a uterotonic agent used to stimulate or augment labor, not to stop it. In the case of preterm labor at 36 weeks, administering oxytocin would worsen the situation by increasing uterine contractions and promoting delivery, which is not the intended goal.

B. Misoprostol: Misoprostol is typically used to induce labor by softening the cervix and stimulating contractions. It is contraindicated in clients experiencing preterm labor, as it would enhance uterine activity and could lead to premature delivery.

C. Magnesium sulfate: Magnesium sulfate is used in preterm labor to provide neuroprotection to the fetus and may also help reduce uterine contractions. It is especially indicated when labor is expected before 32–34 weeks but may still be prescribed at 36 weeks depending on clinical judgment.

D. Indomethacin: Indomethacin is a tocolytic agent used to suppress preterm labor contractions, but it is generally used before 32 weeks due to the risk of premature closure of the ductus arteriosus. At 36 weeks, the risks may outweigh the benefits, so it is not the first-line option at this gestational age.

A. Provide the client with information about what to expect during their care. B. Write the full date on the client's whiteboard. C. Acknowledge the client's feelings. D. Request that the client's family bring the client's eyeglasses from home. E. Request that the client have the same caregivers with every shift. F. Maintain a well-lit environment. G. Reorient the client often. H. Ask the client's partner to stay with the client as much as possible.

Correct Answer is ["B","C","D","E","G","H"]

Explanation

Rationale:

• Write the full date on the client's whiteboard: Writing the date helps reinforce orientation to time, which the client is lacking. Visual cues are essential for reorienting clients with delirium. This simple step can reduce confusion and distress.

• Acknowledge the client's feelings: Acknowledging the client’s fear builds trust and therapeutic rapport. It reduces agitation and reassures the client when they experience hallucinations. Validation helps calm the client without reinforcing delusions.

• Request that the client's family bring the client's eyeglasses from home: Requesting the glasses improves the client’s ability to recognize surroundings. Visual impairment worsens confusion in older adults. Familiar visual aids reduce cognitive strain.

• Request that the client have the same caregivers with every shift: Consistent caregivers help the client form familiar relationships. Continuity reduces confusion, especially in clients with dementia or delirium. Routine and predictability lower anxiety.

• Reorient the client often: Frequent reorientation is key in delirium management. It helps the client regain understanding of time, place, and situation. Repetition promotes memory and reduces disorganized thoughts.

• Ask the client's partner to stay with the client as much as possible: The partner provides emotional comfort and familiarity. Their presence helps maintain the client’s orientation and decreases agitation. Family members often support communication and reorientation.

• Provide the client with information about what to expect during their care: Detailed information may overwhelm or confuse a delirious client. Cognitive overload can worsen disorientation. Simpler, brief explanations are more effective.

• Maintain a well-lit environment: Bright lighting may worsen hallucinations or cause overstimulation. Soft, ambient lighting is better suited for reducing visual misperceptions. Delirious patients benefit from calm, low-stimulation environments.

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A nurse is preparing to perform an abdominal examination for a client who has a gastrointestinal disease. Identify the order in which the nurse should use the examination techniques. (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 assisting in the care of a client who is at 36 weeks of gestation and is in preterm labor. The nurse should expect a prescription for which of the following medications for the client?

Correct Answer is C

Explanation

The nurse is continuing to assist in the care of the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

Correct Answer is ["B","C","D","E","G","H"]

Explanation

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