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
Condition A is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins.
Choice B rationale
Condition B is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins.
Choice C rationale
Condition C, also known as pernicious anemia, is associated with a risk for vitamin B12 deficiency. This condition impairs the body’s ability to absorb vitamin B12 from the gastrointestinal tract.
Choice D rationale
Condition D is not typically associated with a risk for vitamin deficiency. Vitamin deficiencies are usually caused by inadequate intake, poor absorption, or increased demand for vitamins

A. Place enough formula in the feeding bag to last for 8 hr of continuous feeding. B. Flush the tube with 30 mL of water every 4 hr. C. Change the feeding bag and tubing every 72 hr. D. Keep the head of the bed elevated at 15 degrees.

Correct Answer is B

Explanation

Choice A rationale

While it’s important to ensure the feeding bag contains enough formula for the feeding period, it’s not recommended to fill the bag with more than 4-6 hours’ worth of formula at a time due to the risk of bacterial growth.
Choice B rationale
This is the correct answer. Flushing the gastrostomy tube with water every 4 hours helps maintain tube patency and hydrates the patient.
Choice C rationale
Changing the feeding bag and tubing every 72 hours is a common practice, but it’s not the most critical intervention in this scenario.
Choice D rationale
Keeping the head of the bed elevated at 30 to 45 degrees during feeding and for 1 to 2 hours afterward is recommended to minimize the risk of aspiration. However, 15 degrees may not be sufficient.

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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

The nurse is caring for a patient with a condition.The nurse understands that the patient is at risk for vitamin deficiency. What is the condition?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has a gastrostomy tube through which he is receiving continuous enteral feedings. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

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