When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

Inspect

Percuss

Palpate

Auscultate

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: Thoroughly cleansing the affected area helps remove potential pathogens. The Centers for Disease Control and Prevention (CDC) advises washing needlestick injuries with soap and water.

Choice B reason: Squeezing the puncture site is not recommended because it can cause further injury to the tissue and does not effectively reduce the risk of bloodborne pathogen transmission.

Choice C reason: Flushing the puncture site with water is a good practice, but it should be done immediately, not just for 5 minutes. The initial washing is more critical.

Choice D reason: If indicated, postexposure prophylaxis (PEP) should be initiated as soon as possible, ideally within hours of exposure, to maximize its effectiveness. Delaying PEP until the following day is not advisable.

A. Pulse 82/min, client sitting in a chair B. Temperature 36.9°C (98.4°F) C. Respirations auscultated, even at 22/min, client supine D. Blood pressure 108/68 mm Hg

Correct Answer is A

Explanation

Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.

Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.

Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.

Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.

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When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

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Naxlex Comprehensive Predictor Exams

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:

Correct Answer is A

Explanation

When assessing a client's abdomen, particularly for "stomach pain," the nurse should:

A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level?

A nurse has accidentally punctured his finger with a needle he used to give an IM injection to a client. Which of the following actions should the nurse take?

A nurse is changing the dressing on a client's wound. The nurse should recognize that which of the following findings is an indication of a wound infection?

A nurse is reinforcing teaching with a newly licensed nurse about documenting vital signs. Which of the following documentation made by the nurse indicates an understanding of the teaching?

A nurse is caring for a client who is postoperative. When helping to manage the client's pain, which of the following should apply? (Select all that apply)

A nurse is preparing an in-service presentation about preventing healthcare-associated infections (HAIs). The nurse should include which of the following as a common cause of these infections?

Before palpating the abdomen during an assessment, the nurse should do which of the following?