When assessing a client's abdomen, particularly for "stomach pain," the nurse should:
Inspect
Percuss
Palpate
Auscultate
The Correct Answer is D
Choice A reason: Inspection should be performed first to observe for any visible abnormalities, distention, or movements that could indicate underlying conditions.
Choice B reason: Percussion is used after auscultation to assess the presence of fluid, gas, and to estimate the size of the organs within the abdomen.
Choice C reason: Palpation is typically performed last because it can alter the natural state of the abdomen, potentially causing discomfort and affecting the bowel sounds that are assessed during auscultation.
Choice D reason: Auscultation should be performed before palpation and percussion to avoid altering bowel sounds. It allows the nurse to listen to the natural state of bowel motility and vascular sounds without interference.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D","E"]
Explanation
Choice A reason: Expecting the client to express pain both verbally and nonverbally is important in postoperative care. Pain expression is subjective and can vary greatly among individuals. Some clients may verbalize their discomfort, while others may exhibit nonverbal cues such as grimacing, restlessness, or guarding the affected area. It is crucial for nurses to be attentive to all forms of pain expression to assess and manage the client's pain effectively.
Choice B reason: Administering opioids with caution is a standard practice due to the risk of addiction; however, the statement that they will eventually lead to addiction is misleading. Opioids, when used appropriately and under medical supervision, are an effective component of postoperative pain management. The risk of addiction is present but can be mitigated through careful monitoring, patient education, and using the lowest effective dose for the shortest duration necessary.
Choice C reason: Administering analgesics orally for fast-acting pain relief is a common practice, especially when immediate onset is not required. Oral administration is non-invasive and convenient, but it is not the fastest method for pain relief compared to intravenous administration. The choice of analgesic and the route of administration should be based on the client's pain level, type of surgery, and individual needs.
Choice D reason: Using a pain scale from 0 to 10 is an effective way to monitor the severity of the client's pain. This method provides a quantifiable measure of pain intensity, allowing for consistent assessment and facilitating communication between the client and healthcare providers. It helps in evaluating the effectiveness of pain management interventions and in making necessary adjustments to the pain management plan.
Choice E reason: Considering the client's individual expression of pain is essential in postoperative care. Pain is a personal experience, and what may be tolerable for one person could be unbearable for another. Factors such as cultural background, previous pain experiences, psychological state, and the presence of comorbidities can influence pain perception. Tailoring pain management strategies to the individual's needs and preferences is key to effective pain control.
Correct Answer is B
Explanation
Choice A reason: The diaphragm of the stethoscope is used for high-pitched sounds such as breath sounds, bowel, and normal heart sounds. For the apical pulse, which involves listening to the heart's sounds, the bell of the stethoscope is often recommended, especially for lower-pitched sounds like murmurs.
Choice B reason: Counting the apical pulsations for a full minute is the correct action when assessing the apical pulse, particularly for clients on cardiovascular medications. This ensures accuracy in detecting any irregularities or changes in the heart rate that could be affected by the medications.
Choice C reason: The stethoscope should be placed gently against the client's skin. Pressing too firmly can distort the heart sounds, making it difficult to accurately assess the apical pulse.
Choice D reason: A Doppler device is not typically used for routine assessment of the apical pulse. It is more commonly used when pulses are difficult to palpate or auscultate, such as in cases of peripheral arterial disease.
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