The nurse is preparing to perform an abdominal examination. Which step would be taken first?

Auscultation

Inspection

Percussion

Palpation

Answer and Explanation

The Correct Answer is B

Choice A rationale
Auscultation is an important step in an abdominal examination, but it is not the first step. It is performed after inspection and before percussion and palpation to ensure that the motility of the bowel and bowel sounds are not altered.
Choice B rationale
Inspection is the first step in an abdominal examination. This step involves visually examining the abdomen for any abnormalities, such as distension, discoloration, or visible peristalsis. The

nurse observes the color, shape, and movement of the abdomen, and looks for any visible masses, scars, or skin changes. This step provides valuable information about the patient’s overall health and potential issues that may require further investigation.
Choice C rationale
Percussion is a part of the abdominal examination, but it is not the first step. It is performed after inspection and auscultation. During percussion, the nurse taps on the abdomen to assess the size and position of the abdominal organs, and to detect any fluid or masses.
Choice D rationale
Palpation is the last step in an abdominal examination. It is performed after inspection, auscultation, and percussion. During palpation, the nurse uses their hands to feel the abdomen for any masses, tenderness, or organ enlargement.

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Correct Answer is C

Explanation

Choice A rationale
While a sore throat can be a side effect of an upper endoscopy, it is not the priority for monitoring after the procedure.
Choice B rationale
Abdominal bloating can occur after an upper endoscopy, but it is not the priority for monitoring.
Choice C rationale
Monitoring the return of the gag reflex is a priority after an upper endoscopy. The gag reflex may be impaired due to the use of local anesthetics during the procedure. An impaired gag reflex increases the risk of aspiration.
Choice D rationale
Belching can occur after an upper endoscopy, but it is not the priority for monitoring

A. Observe mucous membranes for dryness B. Provide frequent oral care with moist swabs C. Offer the client small sips of water D. Increase the rate of intravenous (IV) fluids

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
Observing mucous membranes for dryness can indicate dehydration.
Choice B rationale

Providing frequent oral care with moist swabs can help alleviate the discomfort of a dry mouth due to NPO status.
Choice C rationale
Offering the client small sips of water is not appropriate as the client is on a diet of nothing by mouth (NPO) except ice chips.
Choice D rationale
Increasing the rate of intravenous (IV) fluids can help prevent dehydration.

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The nurse is preparing to perform an abdominal examination. Which step would be taken first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the plan of care for a client who had an upper endoscopy 1 hr ago. The nurse should place the priority on monitoring which of the following?

Correct Answer is C

Explanation

The nurse is caring for a client who received a new diet prescription from the physician for nothing by mouth (NPO) except ice chips. Which actions would the nurse take to alleviate the effects of dehydration? Select all that apply

Correct Answer is ["A","B","D"]

Explanation

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