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 ["B","C","D"]
Explanation
Choice A reason: Placing a client with active pulmonary TB in a room with positive airflow is not recommended, as positive airflow would push potentially contaminated air into general circulation, risking the spread of TB. Instead, a room with negative airflow is appropriate to contain and remove contaminated air.
Choice B reason: Determining whether the client lives alone or with others is important for public health and contact tracing purposes. If the client lives with others, those individuals may need to be tested and monitored for TB as well.
Choice C reason: Using an alcohol-based hand cleaner is a standard practice unless hands are visibly soiled. If hands are visibly soiled, handwashing with soap and water is necessary.
Choice D reason: Reminding the client to cover their mouth with a tissue when coughing is a key measure to prevent the spread of TB, which is transmitted through airborne particles from coughs or sneezes.
Choice E reason: Antifungal medications are not used to treat TB, which is caused by a bacterium, not a fungus. The client should be instructed about taking anti-tuberculosis medications, not antifungals.
Correct Answer is D
Explanation
Choice A reason: Airborne precautions are used for diseases that are spread through the air over long distances, such as tuberculosis, measles, or chickenpox. VRE is not typically spread through the air.
Choice B reason: Droplet precautions are used for diseases that are spread through large droplets in the air, such as influenza or pertussis. VRE is not spread through droplets but through contact with contaminated surfaces or equipment.
Choice C reason: A protective environment is designed to protect immunocompromised patients from infection and is not typically used for patients with VRE. This type of precaution includes the use of HEPA filters, laminar air flow, and other strategies to maintain a sterile environment.
Choice D reason: Contact precautions are the appropriate measures for a patient with a VRE infection. VRE can be spread from one person to another through contact with contaminated surfaces or equipment or through person-to-person spread, often via contaminated hands. It is not spread through the air by coughing or sneezing. Therefore, contact precautions, including the use of gloves and gowns, are necessary when caring for patients with VRE to prevent the spread of the bacteria.
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