Nokea
A nurse is performing an abdominal assessment on a patient experiencing frequent bouts of diarrhea. The nurse first observes the contour of the abdomen, noting any masses, scars, or areas of distention. What action will the nurse perform next?
- A. Auscultating the abdomen using an orderly clockwise approach in all abdominal quadrants
- B. Percussing all quadrants of the abdomen in a systematic clockwise manner to identify masses, fluid, or air in the abdomen
- C. Lightly palpating over the abdominal quadrants; first checking for any areas of pain or discomfort
- D. Deeply palpating over the abdominal quadrants, noting muscular resistance, tenderness, organ enlargement, or masses
Correct Answer: A
Rationale: The sequence for abdominal assessment is inspection, auscultation, percussion, and palpation. Auscultation (A) follows inspection because palpation may alter bowel sounds. Percussion (B) and palpation (C, D) come later to avoid disturbing peristalsis.
You may also like to solve these questions
A nurse asks a patient for a stool sample to perform the guaiac test. How does the nurse best explain the purpose of this test?
- A. This test replaces the need for screening colonoscopy.
- B. We are looking for infectious organisms in your stool.
- C. The screening assesses for blood in your stool.
- D. This test assesses for antibodies to colon cancer.
Correct Answer: C
Rationale: The guaiac test (C) detects occult blood in stool, screening for GI bleeding or cancer. It doesn't replace colonoscopy (A), detect organisms (B), or assess antibodies (D).
A community health nurse is providing an adult education session about colon cancer. Which signs and symptoms of this cancer will the nurse include? Select all that apply.
- A. Blood in the stool
- B. Previous colonoscopy
- C. Passing two large bowel movements daily
- D. Unintentional weight loss
- E. Upper abdominal cramping
- F. Previous opioid use
Correct Answer: A,D
Rationale: Colon cancer symptoms include blood in the stool (A) and unintentional weight loss (D). Previous colonoscopy (B) and opioid use (F) are not symptoms, two large bowel movements (C) are normal, and upper abdominal cramping (E) is less specific.
A nurse is scheduling tests for a patient who has been experiencing epigastric pain. The health care provider ordered the following tests: (a) barium enema, (b) fecal occult blood test, (c) endoscopic studies, and (d) an upper GI series. What is the correct order for performing the tests?
- A. c, b, d, a
- B. d, c, a, b
- C. a, b, d, c
- D. b, a, d, c
Correct Answer: D
Rationale: Fecal occult blood test (b) comes first to detect bleeding, followed by barium enema (a), upper GI series (d), and endoscopic studies (c) to avoid barium interference and prioritize non-invasive tests (D).
A nurse is caring for an older adult who reports persistent constipation and has a number of laxative prescriptions on the MAR. Which medication would the nurse avoid for this patient?
- A. Saline osmotic laxative
- B. Bulk-forming laxative
- C. Methylcellulose
- D. Stool softener
Correct Answer: A
Rationale: Saline osmotic laxatives (A) can cause fluid/electrolyte imbalances in older adults, especially with kidney or cardiac issues, and should be avoided. Bulk-forming (B, C) and stool softeners (D) are safer options.
A nurse plans to administer a retention enema to a patient with a fecal impaction. Which nursing action is appropriate for this procedure?
- A. Administering a large volume of solution (500 to 1,000 mL)
- B. Mixing milk and molasses in equal parts for an enema
- C. Instructing the patient to retain the enema for at least 30 minutes
- D. Administering the enema while the patient is sitting on the toilet
Correct Answer: C
Rationale: Retention enemas require the patient to hold the solution for at least 30 minutes (C) to soften stool. Large volumes (A) are for cleansing enemas, milk and molasses (B) are for carminative enemas, and administering on the toilet (D) prevents retention.