The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

inspection

percussion

palpation

auscultation

Answer and Explanation

The Correct Answer is A

A. Inspection: Inspection is always the first step in any physical examination, including abdominal assessments. It allows the nurse to visually assess the abdomen for distension, asymmetry, discoloration, or other abnormalities.

B. Percussion: Percussion is performed after inspection and auscultation. It helps assess the density of abdominal contents but should not be the first step.

C. Palpation: Palpation is performed last in an abdominal exam to avoid altering bowel sounds and causing discomfort. It should be done after inspection, auscultation, and percussion.

D. Auscultation: Auscultation is typically the second step after inspection to listen for bowel sounds before palpation and percussion, which might alter them.

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Correct Answer is C

Explanation

A. Sheepskin heel pad: A sheepskin heel pad provides cushioning to prevent pressure ulcers but does not prevent plantar flexion contractures as it does not keep the foot in a neutral position.

B. Abduction pillow: An abduction pillow is used to maintain hip abduction and alignment, typically after hip surgery. It does not address foot positioning or prevent plantar flexion.

C. Footboard: A footboard helps maintain the feet in dorsiflexion, preventing plantar flexion contractures. It keeps the feet at a 90-degree angle to the legs, which is essential for preventing contractures.

D. Trochanter roll: A trochanter roll is used to maintain the alignment of the hips and prevent external rotation of the legs. It does not prevent plantar flexion contractures.

A. Administer oxygen at 2 U/min. B. Raise the head of the bed. C. Encourage coughing and deep breathing D. Administer prescribed analgesic medication

Correct Answer is B

Explanation

A. Administer oxygen at 2 L/min: Administering oxygen is important but should be done after positioning the client to improve natural ventilation.

B. Raise the head of the bed: Raising the head of the bed is the first action to take as it facilitates better lung expansion and improves ventilation. This can help increase the oxygen saturation more immediately and effectively.

C. Encourage coughing and deep breathing: Encouraging coughing and deep breathing is also beneficial to help clear secretions and improve lung function, but positioning the client for optimal breathing should be prioritized first.

D. Administer prescribed analgesic medication. Administering analgesics may be necessary for pain management, but it does not directly address the immediate need to improve oxygen saturation.

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The nurse is assessing a client who reports abdominal pain. Which assessment technique will the nurse perform first?

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