The nurse is mapping the client’s abdomen into four quadrants. Which landmarks should the nurse use to perform this assessment? (Select all that apply)
Umbilicus
Midclavicular lines
Sternum
Lower border of the right ribs.
Correct Answer : A
To map the client's abdomen into four quadrants, the nurse should use the umbilicus as the landmark to perform this assessment. The abdomen is divided into four quadrants by drawing an imaginary line from the center of the umbilicus to the pubic symphysis and another line from the center of the umbilicus to the xiphoid process of the sternum. This helps in identifying the location of any potential abdominal discomfort or tenderness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A visual acuity of 20/25 means that the patient can read letters on an eye chart at 20 feet away, which is the same as what someone with normal vision can read at 25 feet away. This indicates that the patient's visual acuity is slightly below average, but still within the normal range.
Correct Answer is B
Explanation
When assessing the heart, the nurse will inspect and palpate the precordium, which is the area of the chest overlying the heart, and the PMI (point of maximal impulse), which is the point on the chest where the heartbeat is the strongest. These assessments allow the nurse to gather information about the size, shape, and location of the heart and to detect any abnormalities in the heartbeat or rhythm. The peritoneum is a membrane lining the abdominal cavity and has no relevance in the assessment of the heart. The tricuspid area and left sternal border are areas of the chest that may be auscultated to assess heart sounds but are not palpated during a heart assessment.
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