Before palpating the abdomen during an assessment, the nurse should do which of the following?

Put on sterile gloves

Elevate the client's head

Percuss all four quadrants

Auscultate bowel sounds

Answer and Explanation

The Correct Answer is D

Choice A reason: Putting on sterile gloves is not necessary before palpating the abdomen. Sterile gloves are typically used for procedures that require an aseptic technique, such as inserting a catheter or performing a surgical procedure. Palpation of the abdomen is a non-sterile procedure, and clean gloves are usually sufficient to prevent the transmission of microorganisms.

Choice B reason: Elevating the client's head is not a standard preparatory step before palpating the abdomen. While it may be necessary to adjust the client's position for comfort or to assess certain areas, the head elevation is not specifically related to the palpation process. The client should be in a supine position with knees slightly bent to relax the abdominal muscles, which facilitates palpation.

Choice C reason: Percussion of all four quadrants is part of the abdominal assessment but is not the step that precedes palpation. Percussion is used to assess the size and density of abdominal organs, detect the presence of fluid or gas, and evaluate tenderness. However, the correct sequence of abdominal assessment is inspection, auscultation, percussion, and then palpation.

Choice D reason: Auscultating bowel sounds is the correct action before palpating the abdomen. This is because palpation can alter bowel motility, which may change the sounds heard. Auscultation should be performed after inspection and before percussion and palpation to obtain an accurate assessment of bowel activity. Normal bowel sounds range from 5 to 30 per minute and are characterized by clicks and gurgles.

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Correct Answer is B

Explanation

Choice A reason: Scarlet fever is caused by a bacterium that produces a toxin leading to a rash. It is typically spread through respiratory droplets, and while standard precautions are necessary, an N95 respirator is not required.

Choice B reason: Tuberculosis is an airborne infectious disease that requires the use of an N95 respirator to protect against inhaling the bacteria, especially in cases of pulmonary tuberculosis. This type of respirator filters out at least 95% of airborne particles, including Mycobacterium tuberculosis.

Choice C reason: Mycoplasmal pneumonia, also known as "walking pneumonia," is caused by Mycoplasma pneumoniae and is typically less severe than other types of bacterial pneumonia. Standard precautions, including the use of surgical masks, may be sufficient unless there is a risk of aerosol-generating procedures.

Choice D reason: Scabies is caused by a mite that burrows into the skin. It is spread through direct skin-to-skin contact, and an N95 respirator is not needed for protection against scabies.

A. Carotid B. Popliteal C. Femoral D. Brachial

Correct Answer is A

Explanation

Choice A reason: The carotid pulse sites should not be checked bilaterally at the same time because palpating both carotid arteries simultaneously can restrict blood flow to the brain and may also stimulate the vagus nerve, potentially causing bradycardia or even syncope.

Choice B reason: The popliteal pulse, located at the back of the knee, can be checked bilaterally without the risk of restricting blood flow to vital organs or stimulating a vagal response.

Choice C reason: The femoral pulse, found in the groin area, can also be checked bilaterally as it does not pose the same risks as the carotid pulse when checked simultaneously.

Choice D reason: The brachial pulse, located on the inside of the arm just above the elbow, is another site that can be checked bilaterally without significant risk.

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Before palpating the abdomen during an assessment, the nurse should do which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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