Which position would be appropriate for the nurse to perform an abdominal assessment?

lithotomy with a drape for privacy

Supine with arms at their sides

left decubitus

a position that feels most comfortable for the client

Answer and Explanation

The Correct Answer is B

A. Lithotomy with a drape for privacy: The lithotomy position, where the client lies on their back with hips and knees flexed and legs supported in stirrups, is typically used for gynecological examinations or procedures. While this position provides access to the abdominal area, it is not typically used for routine abdominal assessments. Additionally, draping for privacy may not be necessary for a routine abdominal assessment.

B. Supine with arms at their sides: This is the most appropriate position for performing an abdominal assessment. In the supine position, the client lies on their back with arms at their sides, which allows for easy access to the abdomen. The supine position provides optimal relaxation of abdominal muscles and facilitates palpation and auscultation of abdominal organs.

C. Left decubitus: The left decubitus position, where the client lies on their left side with the right knee flexed, is sometimes used to facilitate gastric emptying and reduce gastroesophageal reflux. While this position may provide some access to the abdominal area, it is not typically used for routine abdominal assessments.

D. A position that feels most comfortable for the client: While it is essential to consider the client's comfort during any assessment, the position that feels most comfortable for the client may not always be the most suitable for performing an abdominal assessment. The supine position with arms at their sides is the standard position for abdominal assessments due to its ease of access and optimal relaxation of abdominal muscles.

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Correct Answer is B

Explanation

A. Isotonic fluid helps the client feel less thirsty when they are NPO: While isotonic fluids can help maintain hydration status, they do not directly address the sensation of thirst. Isotonic fluids replace extracellular fluid volume and help maintain electrolyte balance but do not affect the sensation of thirst.

B. This type of IV hydration replaces blood volume without affecting intracellular fluid: This is the correct property of isotonic fluid replacement. Isotonic IV fluids have a similar osmolarity to extracellular fluid and thus replace fluid volume without significantly impacting the distribution of water between intra- and extracellular compartments. They are effective for expanding intravascular volume without causing a significant shift of water into or out of cells.

C. Isotonic IV hydration can cause cells to burst if given too rapidly: Isotonic IV fluids have the same osmotic pressure as blood plasma and therefore do not cause cells to burst when administered at appropriate rates. It is hypertonic solutions that can cause cells to shrink or swell due to osmotic imbalances.

D. This type of IV fluid must be given in an intensive care setting with frequent monitoring of the client's vital signs: While isotonic fluids are commonly used in various clinical settings, including intensive care, they do not inherently require administration in an intensive care setting with frequent monitoring of vital signs. Isotonic fluids are often administered in routine medical-surgical settings for various fluid balance problems.

A. 17-year-old who has just had an ankle cast applied. B. 60-year-old recovering from a heart attack. C. 80-year-old admitted for an infected tooth. D. 28-year-old new mother of twins.

Correct Answer is B

Explanation

A. 17-year-old who has just had an ankle cast applied: While constipation may occur due to reduced mobility after having an ankle cast applied, teaching about the hazards of straining during bowel movements is not the priority for this client. The immediate concern may be related to cast care and mobility.

B. 60-year-old recovering from a heart attack: This client is recovering from a heart attack, and straining during bowel movements can increase intra-abdominal pressure and potentially lead to complications such as vagal stimulation, which may trigger arrhythmias or further stress the heart. Therefore, teaching about the hazards of straining during bowel movements is essential for this client to prevent complications and promote cardiac safety.

C. 80-year-old admitted for an infected tooth: While constipation may occur as a side effect of certain medications or due to decreased oral intake, teaching about straining during bowel movements is not the immediate priority for this client, given the primary reason for admission is an infected tooth. However, if constipation becomes a concern during the admission, it can be addressed accordingly.

D. 28-year-old new mother of twins: While postpartum mothers may experience constipation due to various factors such as changes in hormone levels, reduced mobility after delivery, and opioid use for pain management, teaching about the hazards of straining during bowel movements may not be the priority compared to other immediate postpartum care needs, such as breastfeeding support, perineal care, and newborn care.

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Which position would be appropriate for the nurse to perform an abdominal assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is prescribed isotonic IV hydration for their current fluid balance problem. Which property of isotonic fluid replacement is essential for the nurse to understand?

Correct Answer is B

Explanation

The nurse is prioritizing the day's interventions. Which client should be the first to be taught about the hazards of straining when having a bowel movement? The:

Correct Answer is B

Explanation

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A nurse is caring for a client being treated for a fluid volume excess. Which clinical finding validates the client's fluid status?

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