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 A

Explanation

Choice A reason: This response demonstrates empathy and active listening. It acknowledges the client's feelings without judgment and opens the door for further discussion about their concerns. It is a therapeutic communication technique that helps build rapport and trust between the nurse and the client. When a client feels understood, it can reduce their anxiety and promote a sense of safety, which may improve their ability to sleep and concentrate.

Choice B reason: While it is important for clients to communicate with their healthcare providers, this response might make the client feel dismissed or that their immediate concerns are not being addressed by the nurse. It could be perceived as deflecting the responsibility to someone else, rather than the nurse providing support at that moment.

Choice C reason: Asking the client to self-reflect on the reasons for their anxiety could be helpful, but it might also be overwhelming for them if they are already in a heightened state of anxiety. This question should be asked with caution and at an appropriate time when the client is more likely to engage in productive self-reflection.

Choice D reason: This statement minimizes the client's experience by suggesting that their problem is common and insignificant. It fails to acknowledge the severity of the client's distress and does not offer any comfort or assistance. It is not a therapeutic response because it does not validate the client's feelings or encourage further communication.

A. Offer the client a beverage of choice B. Establish that insurance coverage exists C. Establish a rapport with the patient D. Ask the patient to disrobe and put on a gown

Correct Answer is C

Explanation

Choice A reason: Offering a beverage is a hospitable gesture but not the first step in taking a health history. The priority is to establish communication and trust.

Choice B reason: Confirming insurance coverage is important but not the initial step in the health history process. The focus should first be on the patient's immediate needs and concerns.

Choice C reason: Establishing a rapport with the patient is the first and most crucial step in taking a health history. It involves creating a comfortable and trusting environment for the patient to share personal health information.

Choice D reason: Asking the patient to disrobe and put on a gown may be necessary for a physical examination but is not the first step in taking a health history. The nurse should first establish a rapport with the patient.

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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

A nurse is caring for a client who reports a state of increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

Correct Answer is A

Explanation

Prior to taking the health history, the nurse should first do which of the following?

Correct Answer is C

Explanation

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