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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is: a. Edema.
Choice A: Edema
Edema is swelling caused by excess fluid trapped in the body’s tissues. It is a common sign of inflammation and infection. When a wound becomes infected, the body’s immune response can cause increased fluid accumulation in the affected area, leading to noticeable swelling. This swelling is often accompanied by redness, warmth, and pain, which are classic signs of infection.
Choice B: Petechiae
Petechiae are small, red or purple spots caused by bleeding into the skin. They are not typically associated with wound infections but rather with conditions that cause bleeding or clotting disorders. Petechiae do not indicate an infection but rather a different underlying issue that may require further investigation.
Choice C: Urticaria
Urticaria, also known as hives, is a skin reaction that causes itchy welts. It is usually a result of an allergic reaction and is not a sign of wound infection. Urticaria is characterized by raised, red, itchy bumps on the skin and does not typically occur in response to an infected wound.
Choice D: Crusting over granulated tissue
Crusting over granulated tissue is a normal part of the wound healing process. Granulation tissue forms as the wound heals, and a crust or scab may develop over it to protect the new tissue underneath. This is not an indication of infection but rather a sign that the wound is progressing through the healing stages.
Correct Answer is B
Explanation
Choice A reason: Droplet precautions are used for diseases that are spread by large respiratory droplets produced by coughing, sneezing, or talking. Examples include influenza, pertussis, and mumps. However, tuberculosis is not spread through large droplets but through airborne particles that can remain suspended in the air for long periods.
Choice B reason: Airborne precautions are necessary for diseases that are transmitted by smaller droplets, which can be suspended in the air for extended periods and can be inhaled. Tuberculosis, particularly pulmonary or laryngeal tuberculosis with a productive cough, requires airborne precautions because the bacteria can be expelled into the air and inhaled by others. The nurse should initiate airborne precautions, which include placing the patient in a negative pressure room and using personal protective equipment such as N95 respirators.
Choice C reason: Contact precautions are used for infections that are spread by direct contact with the patient or the patient's environment. Examples include infections caused by multidrug-resistant organisms, scabies, and norovirus. Tuberculosis is not spread by direct contact, so contact precautions are not the primary method of prevention.
Choice D reason: Protective isolation, also known as neutropenic or reverse isolation, is used to protect immunocompromised patients from infections. It is not used for patients with tuberculosis, as the goal is to protect others from the tuberculosis bacteria, not to protect the patient from external infections.
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