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 C

Explanation

The correct answer is: c. Positioning the client’s arm above heart level.

Choice A: Wrapping the cuff too loosely around the client’s arm

Wrapping the cuff too loosely can lead to an inaccurately high blood pressure reading, not a low one. A loose cuff does not compress the artery properly, causing the device to overestimate the pressure needed to occlude the artery.

Choice B: Measuring blood pressure right after the client’s mealtime

Measuring blood pressure right after a meal can cause a slight increase in blood pressure due to the body’s metabolic response to digestion. This is not a common cause of a low blood pressure reading.

Choice C: Positioning the client’s arm above heart level

Positioning the client’s arm above heart level can lead to an inaccurately low blood pressure reading. When the arm is elevated, the hydrostatic pressure decreases, resulting in a lower reading. This is a well-known source of error in blood pressure measurement.

Choice D: Deflating the cuff too slowly

Deflating the cuff too slowly can cause venous congestion, which may lead to an inaccurately high reading rather than a low one. The standard deflation rate is 2-3 mm Hg per second to ensure accurate measurement.

A. "I will avoid drinking large amounts of fluids immediately before bedtime." B. "I will limit having a glass of wine to just before bedtime." C. "I will walk briskly for 30 minutes before bedtime." D. "I will do my muscle relaxation techniques in the afternoon." E. Instruct the client about taking antifungal medications.

Correct Answer is A

Explanation

Choice A reason: Avoiding large amounts of fluids before bedtime can help prevent disruptions in sleep due to the need to urinate during the night.

Choice B reason: Consuming alcohol, even in the form of a glass of wine, just before bedtime can interfere with the sleep cycle and lead to disrupted sleep.

Choice C reason: Engaging in brisk exercise before bedtime can be stimulating and may make it more difficult to fall asleep.

Choice D reason: Performing muscle relaxation techniques in the afternoon can help reduce overall tension but doing them closer to bedtime would be more beneficial for promoting sleep.

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

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Naxlex Comprehensive Predictor Exams

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Correct Answer is C

Explanation

Choice A: Wrapping the cuff too loosely around the client’s arm

Choice B: Measuring blood pressure right after the client’s mealtime

Choice C: Positioning the client’s arm above heart level

Choice D: Deflating the cuff too slowly

A nurse is reinforcing teaching about promoting rest and sleep with a client who reports insomnia. Which of the following statements should the nurse identify as an indication that the client understands the teaching?

Correct Answer is A

Explanation

A nurse is assisting with the admission of a client who has tuberculosis with a productive cough. Which type of isolation precautions should the nurse initiate for the client?

A nurse is caring for a client who was placed on isolation precautions for active pulmonary tuberculosis (TB). Which of the following actions should the nurse plan to take? (Select all that apply.)

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

For the client who reports pain, the nurse should consider the following as the most reliable indicator of pain:

A nurse is reinforcing teaching with a client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

A nurse is collecting data from a client who has insomnia. The nurse should identify that which of the following is likely to disrupt sleep?

A nurse in a pediatric unit is planning care for a group of clients. Which of the following clients should the nurse plan to use the Crying, Requires oxygen, Increased vital signs, Expression, Sleeplessness (CRIES) pain scale?

When assessing a client's abdomen, particularly for "stomach pain," the nurse should: